Intervenciones psicosociales para el daño autoinfligido en adultos
Referencias
Referencias de los estudios incluidos en esta revisión
Referencias de los estudios excluidos de esta revisión
Referencias de los estudios en espera de evaluación
Referencias de los estudios en curso
Referencias adicionales
Referencias de otras versiones publicadas de esta revisión
Characteristics of studies
Characteristics of included studies [ordered by study ID]
| Study characteristics | ||
| Methods | Allocation: random assignment using sealed and numbered envelopes Follow‐up period: 24 months after trial entry N lost to follow‐up: 24/150 (16%) for repetition data | |
| Participants | Inclusion criteria: i) resident in catchment area of hospital; ii) able to speak French or English; iii) no physical handicap preventing attendance; iv) not already in institutional care; v) capacity to give informed consent; vi) not sociopathic; vii) suicide attempt was made within one week prior to trial entry Exclusion criteria: i) no fixed address; ii) expecting to move out of the catchment area; iii) in the care of an institution that ensures follow‐up after all suicide attempts; iv) diagnosed with a physical disability that would prevent attendance at follow‐up sessions; v) unable to provide informed consent; vi) diagnosed with sociopathy and presents a physical threat to hospital personnel; vii) suicide attempt occurred a week or more prior to randomisation Numbers: Of the 150 participants, 76 were allocated to the experimental arm and 74 to the control arm. Profile: 55% (n = 83) were female. 50% (n = 75) were repeaters. 87% (n = 131) had diagnosis of depression, 53% (n = 80) substance abuse diagnosis, and 45% (n = 68) were diagnosed with a personality disorder. Source of participants: patients presenting to hospital following a suicide attempt Location: Montreal, Canada | |
| Interventions | Experimental: intensive intervention involving a schedule of visits, including at least one home visit. Therapy provided where needed. Reminders (telephone or written) and home visits were made in case of missed appointments. Control: treatment by the regular personnel within the same hospital Therapist: 1 social worker Type of therapy offered: various interventions offered to participants in the experimental arm, including: psychoanalytic psychotherapy, psychosocial, drug therapy, behavioural therapy, or a combination of these Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH according to hospital records, Coroner's office records, interviews with participants or collateral informants, or a combination of these; ii) suicide; iii) compliance measured as encounters with therapist Excluded: none | |
| Notes | Sources of funding: no details on funding are provided Declaration of author interests: no details on author interests are provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Subjects were randomly assigned either to the intensive intervention group or to the comparison group, using sealed and numbered envelopes" (p. 306) Comment: No mention of how the sequence was generated or how envelopes were numbered. It is therefore unclear if the allocation sequence was adequately generated. |
| Allocation concealment (selection bias) | Low risk | Quote: "Subjects were randomly assigned either to the intensive intervention group or to the comparison group, using sealed and numbered envelopes" (p. 306) Comment: No mention of whether the envelopes were opaque or not, although they probably were. |
| Blinding (performance bias and detection bias) | High risk | Quote: "If in the experimental group, subjects. . . were put under the care of the project team (two staff psychiatrists and a social worker); if in the comparison group, they were treated by other personnel" (p. 306) Comment: It is not known whether the participants were aware they were being treated by a different team or not, although the nature of the intervention means it is likely participants were aware of which treatment group they had been assigned to. |
| Blinding (performance bias and detection bias) | High risk | Quote: "If in the experimental group, subjects. . . were put under the care of the project team (two staff psychiatrists and a social worker); if in the comparison group, they were treated by other personnel" (p. 306) Comment: Personnel would have been aware of which team they had been assigned to. |
| Blinding (performance bias and detection bias) | High risk | Quote: "For most of the study, patients in the experimental group were interviewed at 12 months by their psychiatrist (instead of the research assistant)" (p. 307) Comment: If personnel were also acting as outcome assessors they would not have been blinded to allocation for the above reason. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All comparisons between groups were made on an intention‐to‐treat basis" (p. 307) Comment: Within the section on 'Losses to follow‐up', the authors state that follow‐up information was not available for 24 participants. No reasons for dropouts were provided in this section. The authors do, however, assert these losses were unlikely to introduce bias and "unlikely to affect the comparisons between the two groups" (pp. 308‐309) as dropouts (who shared a similar demographic profile) were "equally distributed between groups". |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not reported; however, in the absence of the trial protocol this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: offsite random assignment made using a stochastic minimisation programme (MINIM) balanced for age (18‐25, 26‐30, and > 30 years), sex, and diagnosis of antisocial personality disorder Follow‐up period: 6, 12, and 18 months N lost to follow‐up: 8/134 (6.0%) at the 18‐month follow‐up period | |
| Participants | Inclusion criteria: i) diagnosed with borderline personality disorder; ii) made a suicide attempt or an episode of SH within 6 months prior to randomisation; iii) aged 18‐65 years Exclusion criteria: i) currently in long‐term psychotherapeutic treatment; ii) met DSM‐IV criteria for any psychosis or bipolar I disorder; iii) dependent on any opiate to such a degree that specialist treatment was required; iv) presence of a mental impairment or evidence of an organic brain disorder Numbers: Of the 134 participants, 71 were allocated to the experimental arm and 63 to the control arm. Profile: 80% (n = 107) were female,100% (n = 134) were multiple repeaters, 56% (n = 75) were diagnosed with major depression, 77% (n = 103) were diagnosed with a milder depressive disorder such as dysthymia, 14% (n = 19) were diagnosed with post‐traumatic stress disorder, 61% (n = 82) were diagnosed with an anxiety disorder, 54% (n = 72) were diagnosed with a substance use disorder, 28% (n = 37) were diagnosed with an eating disorder, 13% (n = 17) were diagnosed with somatoform disorder, and 28% (n = 37) were diagnosed with comorbid antisocial personality disorder Source of participants: consecutive referrals to 1 of 2 community outpatient psychiatric facilities, 1 of which provides specific treatment for personality disorder Location: London, UK | |
| Interventions | Experimental: mentalisation‐based treatment involving weekly individual and group sessions of psychotherapy. Participants were also prescribed medication (e.g., antidepressants, antipsychotics, mood stabilisers, minor tranquillizers) as needed. Control: structured case management involving 3 monthly individual and group sessions based on a counselling model resembling a supportive approach combined with case management, advocacy support, and problem‐solving psychotherapy. Participants were also prescribed any medication (e.g., antidepressants, antipsychotics, mood stabilisers, minor tranquillizers) as needed. Therapist: 2 psychotherapists Type of therapy offered: mentalisation‐based psychotherapy Length of treatment: 18 months | |
| Outcomes | Included: i) repetition of SH, ii) repetition of suicide attempts; iii) suicides; iv). compliance; v) depression scores. Excluded: i) psychiatric readmissions; ii) length of psychiatric readmissions; iii) medication use; iv) social functioning scores; v) symptom distress scores; vi) social adjustment scores; vii) interpersonal functioning scores | |
| Notes | Sources of funding: "Supported by a grant from the Borderline Personality Disorder Research Foundation" (p. 1363). Declaration of author interests: none stated Other: repetition data for SH, suicide attempts, and completed suicides was obtained through correspondence with Dr Fonagy | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Treatment allocation was made offsite via telephone randomisation using a stochastic minimization program (MINIM)" (p. 1356). Comment: Use of a computerised algorithm is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "Treatment allocation was made offsite" (p. 1356). Comment: Use of offsite allocation is likely to have ensured allocation was adequately concealed. |
| Blinding (performance bias and detection bias) | High risk | Comment: no mention of participant blinding; however, the nature of the trial means it is likely participants were aware of which treatment group they had been assigned to |
| Blinding (performance bias and detection bias) | High risk | Comment: No mention of personnel blinding is made; however, the nature of the trial means it is likely that therapists knew which treatment they were providing |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Independent evaluators blind to treatment allocation conducted assessments." (p. 1355). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All results were analysed using an intention‐to‐treat analysis based on treatment assignment" (p. 1359). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not reported; however, in the absence of the trial protocol this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a predetermined computer‐generated random number procedure Follow‐up period: 12 months N lost to follow‐up: 0/327 (0%) for repetition of SH | |
| Participants | Inclusion criteria: i) aged 16 or older; ii) admitted to a psychiatric emergency service following an episode of SH or attempted suicide; iii) resident in New Zealand; iv) able to understand English well enough to provide informed consent Exclusion criteria: none stated Numbers: Of the 327 participants, 153 were allocated to the experimental arm and 174 were allocated to the control arm. Profile: 66.0% (n = 216) were female, 17.7% (n = 58) were multiple repeaters Source of participants: patients admitted to a psychiatric emergency service following an episode of SH or attempted suicide Location: Christchurch, New Zealand | |
| Interventions | Experimental: postcards mailed at 2 and 6 weeks and 3, 6, 9, and 12 months after discharge in addition to usual care Control: TAU involving crisis assessment and referral to inpatient community‐based mental health services as required Therapist: none Type of therapy offered: outreach through the mailing of frequent postcards encouraging participants to make contact with the service Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide Excluded: i) number of re‐presentations to psychiatric emergency services | |
| Notes | Source of funding: "This study was supported by grants from the Canterbury District Health Board and the Accident Compensation Corporation (ACC). S.J.G. was supported by a University of Otago Postgraduate Publishing Bursary" (p. 59). Declaration of author interests: none stated. Other: Data on repetition of SH were obtained from psychiatric emergency service records, hospital medical records, or both. Data on suicides were obtained following correspondence with authors. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Participants were randomised 1:1 . . . using predetermined computer‐generated random numbers. . . The number sequence was computer‐generated in SAS 9.1 for Windows using a uniform distribution to generate a sequence of random numbers between 0 and 1. Numbers of 0.5 or above were classified as the intervention group; numbers below 0.5 were classified as the control group." (p. 56). Comment: Use of a computer‐generated list is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "Randomisation was performed. . . by research staff who were not involved in the recruitment or clinical care of participants" (p.56). |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Participants' randomisation status was not conveyed to clinical. . . staff" (p. 56). |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Participants' randomisation status was not conveyed to. . . data‐collection staff" (p. 56). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: ". . . results of the trial were analysed using the intention‐to‐treat design" (p. 56). |
| Selective reporting (reporting bias) | Unclear risk | Comment: Data on suicides had to be requested from authors, suggesting that selective reporting bias may have been present. In the absence of the trial protocol; however, the degree of selective reporting cannot be ascertained. |
| Other bias | High risk | Quote: "[T]here was a significant difference between the groups in the number of prior attendances for self‐harm in the [12 months prior to randomisation] with the number of prior attendances being lower in the intervention than in the control group . . . the reduced number of re‐presentations for self‐harm in the intervention group . . . may reflect a pre‐existing tendency for those in the intervention group to have lower numbers of prior hospital attendances for self‐harm. . . Adjusting for the number of prior hospital visits for self‐harm reduced, and in many cases removed, the effect of the intervention on re‐presentation for self‐harm" (pp. 57‐58). |
| Study characteristics | ||
| Methods | Allocation: Primary care practices were stratified into 4 groups according to rate of SH. Practices were divided again into 2 groups (8 groups total) according to practice size. Allocation was then made using a random numbers table. Follow‐up period: 12 months N lost to follow‐up: 0/1932 (0%) for repetition data | |
| Participants | Inclusion criteria: for primary care practices: i) based in geographical area whose patients lived in catchment area of 4 general hospitals. For participants: i) found in general hospital case register for SH; ii) recruitment data collected weekly from hospitals' A&E sites; iii) not an alcohol (taken alone) or illicit drug overdose, except where casualty officer felt purpose was SH or suicide; iv) aged 16 years and older; v) of fixed residence Exclusion criteria: i) imprisoned; ii) made a request that no one be informed of SH episode; iii) SH occurred in direct response to a hallucination or delusion; iv) SH episode managed entirely in primary care Numbers: Of the 98 primary care practices, 49 were assigned to the experimental arm and 49 to the control arm. Of the 1932 participants, 964 were assigned to the experimental arm, and 968 to the control arm. Profile: 59% (n = 1140) female, 12.6% (n = 244) were repeaters (based on case register information) Source of participants: patients presenting to hospital following an episode of SH and who are also registered with one of the participating primary care practices Location: Avon, Wiltshire, and Somerset, UK | |
| Interventions | Experimental: letter from GP inviting patient to a consultation with GP (provided with management guideline) Control: usual care involving GP, psychiatric or other referral Therapist: GPs Type of therapy offered: one‐off consultation in GP practice Length of treatment: one‐off consultation | |
| Outcomes | Included: i) repetition of SH according to hospital case registers; ii) contact with services Excluded: i) initiation of contact from GP; ii) days to first repeat SH episode | |
| Notes | Sources of funding: "National Health Service South West Research and Development Directorate" (p. 1260). Decalartion of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "98 general practices were assigned in equal numbers to an intervention or a control group" (p. 1254) Comment: correspondence with authors confirmed that a random numbers table had been used to generate the allocation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors confirmed that primary care practices were stratified into 4 groups according to rate of SH, were divided again into 2 groups (8 groups total) according to practice size, and were then allocated using random numbers tables by individuals blind to identity of practices. It is likely this process was adequately concealed. |
| Blinding (performance bias and detection bias) | High risk | Quote: "The intervention comprised a letter from the general practitioner inviting the patient to consult" (p. 1254) Comment: It is therefore likely that participants aware of their allocation to the intervention arm. |
| Blinding (performance bias and detection bias) | High risk | Quote: "The intervention comprised a letter from the general practitioner inviting the patient to consult" (p. 1254) Comment: It is therefore likely that GPs were aware of which arm a participant had been assigned. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on blinding of outcome assessors were provided |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "For the primary analysis, which compared the intervention and control groups on an intention to treat basis, we carried out a logistic regression analysis with repeat episodes of deliberate self‐harm within 12 months of the index event as the outcome variable. This analysis controlled for practice size (two categories) and quartile of rates of deliberate self‐harm by practice at baseline and allowed for clustering by practice, using random effects logistic regression. We used a Poisson regression analysis to compare the intervention and control groups in terms of differences in the number of repeat episodes. We used Cox's proportional hazards regression for time (in days) to first repeat episode. Clustering was taken into account for both of these (intention‐to‐treat) analyses" (p. 1255) |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computer randomisation sequence programmed to prohibit more than 7 consecutive assignments in the same treatment group Follow‐up period: 18 months N lost to follow‐up: 35/120 (29%) for repetition data | |
| Participants | Inclusion criteria: i) attempted suicide and received medical/psychiatric evaluation within 48 hours of attempt; ii) able to provide at least 2 verifiable contacts; iii) 16 years or older; iv) able to speak English; v) able to complete baseline assessment; vi) able to provide informed consent Exclusion criteria: i) diagnosed with any medical disorder that would prevent participation in an outpatient clinical trial Numbers: Of the 120 participants, 60 were allocated to the experimental arm, and 60 to the control arm. Profile: 61% (n = 73) female. 74% (n = 89) were repeaters. 68% (n = 82) were diagnosed with substance abuse, and 77% (n = 92) were diagnosed with major depressive disorder Source of participants: patients presenting to hospital after suicide attempt Location: Pennsylvania, USA | |
| Interventions | Experimental: 10 sessions of cognitive therapy in addition to treatment as usual Control: TAU Therapist: outpatient sessions were delivered by trial therapists Type of therapy offered: cognitive therapy Length of treatment: 10‐20 weeks | |
| Outcomes | Included: i) repetition of SH according to self‐report; ii) suicide; iii) suicidal ideation scores; iv) depression scores; v) hopelessness scores Excluded: i) adherence (due to nature of data reported) | |
| Notes | Sources of funding: "This research was supported by grants R01 MH60915 and P20 MH71905 from the National Institute of Mental Health and grant R37 CCR316866 from the Centers for Disease Control and prevention" (p. 570). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "A computerized randomization sequence programmed to prohibit more than 7 consecutive assignments in either treatment group was used" (p. 564) Comment: Use of a computerised algorithm is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Quote: "Participants. . . were randomly assigned to cognitive therapy or usual care" (p. 564) Comment: Due to the nature of the intervention treatment, it is unlikely participants could have been blinded to which treatment they had been assigned. |
| Blinding (performance bias and detection bias) | High risk | Comment: Due to the nature of the intervention treatment, it is unlikely therapists could have been blinded to which treatment they were delivering. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Although blinded assessments were conducted at baseline, blinded follow‐up evaluations were not possible" (p.5 64) |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All effectiveness analyses were conducted using the intent‐to‐treat (ITT) principle" (p. 565) Additionally, "[t]ests and estimates of ITT differences for both continuous and binary outcomes were based on longitudinal models with random effects" (p. 566) Comment: of the 120 randomised participants, 2 dropped out during the intervention and 35 were lost to follow‐up at 18 months. Reasons were given for dropouts. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias. Care was taken to test for differences between groups with respect to other care, including psychotropic medications and treatments for substance misuse, but no significant differences were found. |
| Study characteristics | ||
| Methods | Allocation: randomisation based on Zelen's method using a computer generated randomisation schedule Follow‐up period: 24 months N lost to follow‐up: 0/772 (0%) for repetition data | |
| Participants | Inclusion criteria: i) aged over 16 years; ii) presented to a toxicology service with deliberate self‐poisoning; iii) able to provide informed consent; iv) fixed address; v) sufficient English; vi) did not pose a potential threat to the interviewer Numbers: Of the 772 participants, 378 were allocated to the experimental arm, and 394 to the control arm. Profile: 68% (n = 525) female, 17% (n = 131) were repeaters. 43% (n = 333) were diagnosed with any affective disorder, 13% (n = 104) with alcohol abuse or dependence, 40% (n = 311) with other substance‐related disorders, and 22% (n = 169) with any personality disorder Source of participants: patients presenting to hospital toxicology service Location: Hunter Valley, NSW, Australia | |
| Interventions | Experimental: postcards mailed at 1, 2, 3, 4, 6, 8, 10, and 12 months after discharge in addition to usual care Control: usual care Therapist: none Type of therapy offered: outreach through the mailing of frequent postcards encouraging participants to make contact with the service Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH according to hospital databases; ii) suicide Excluded: none | |
| Notes | Sources of funding: "KC is funded by the NSW Health, Burdekin Mental Health Enhancement Strategy" (p. 4). Declaration of author interests: none stated Other: data on suicides obtained following correspondence with the authors. 20 control group participants received intervention due to clerical errors but were included by the authors in the control group for all intention‐to‐treat analyses | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Randomisation was by database (HanDBase, version 2.0, DDH Softwards, FL, USA) on a personal digital assistant (Palm III, Palm, CA, USA) that was populated with a pre‐generated randomisation schedule (in blocks of 10) . . . " (p. 2). Comment: Use of a computerised program is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | High risk | Comment: As consent was obtained using Zelen's method, participants were given the option to change treatment arms following allocation. Therefore, allocation cannot have been concealed. |
| Blinding (performance bias and detection bias) | High risk | Quote: "We used a randomised consent design, using the single consent version (Zelen's design). This design is a variation on the standard randomised controlled experimental design, where participants are randomised to control or intervention before consent is sought. In the single consent version, written informed consent to receive the intervention (eight non‐obligatory postcards) was sought from participants randomised to the intervention." (p. 2). Comment: As participants were required to give consent to the treatment they were receiving, blinding to allocation status could not have been maintained. |
| Blinding (performance bias and detection bias) | High risk | Quote: " [The] secretary responsible for managing the mailing database and postcards [was] not blind to allocation status" (p. 4). Comment: As personnel knew whether or not a postcard had been sent, they could not have been blinded to allocation status. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "All other. . . research staff remained blinded to allocation." (p. 2) |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "We assessed the outcomes by an intention to treat analysis on the basis of allocation" (p. 2). |
| Selective reporting (reporting bias) | Unclear risk | Comment: Data on completed suicides had to be obtained through correspondence with the authors. In the absence of the trial protocol, the degree of selective reporting cannot be ascertained. |
| Other bias | High risk | Quote: "Twenty participants in the control group received the intervention due to clerical errors but were included in the control group for the intention to treat analyses." (p. 2). Comment: The inclusion of participants who received the treatment intervention within the control group may lead to bias in the estimation of the treatment effect. |
| Study characteristics | ||
| Methods | Allocation: randomisation in groups of 2 or 4 using sealed envelopes Follow‐up period: 12 months N lost to follow‐up: 44/216 (20%) for repetition data | |
| Participants | Inclusion criteria: i) individuals treated after suicide attempt Numbers: Of the 216 participants, 107 were allocated to the experimental arm and 109 to the control arm. Profile: 66% (n = 143) were female, 52% (n = 112) were repeaters, and 91% (n = 197) were diagnosed with a mood disorder Source of participants: patients treated in hospital after suicide attempt Location: Lund, Sweden | |
| Interventions | Experimental: telephone contact (20‐45 minutes) at 4 and 8 months to increase motivation in addition to usual care Control: usual care Therapist: therapists with at least 10 years' experience working with suicidal individuals Type of therapy offered: motivational therapy Length of treatment: 8 months | |
| Outcomes | Included: i) repetition of SH according to self‐report checked against both patient records and admission charts; ii) suicide; iii) suicidal ideation scores; iv) compliance Excluded: i) global functioning scores; ii) psychiatric symptoms scores | |
| Notes | Sources of funding: "This study was supported by grants from The Axson Johnsons foundation and from the Vardal Foundation (V97 341)" (p. 90) Declaration of author interests: No details on author interests are provided. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Random allocation" and "personal (sic) . . . performed the randomisation" (p. 83). Comment: The trialists appear to have conducted randomisation using the matched pair design, as blocks of 2 or 4 patients were randomised. Although it is likely the random sequence was adequately generated, without further information on the method used, we cannot ascertain this. |
| Allocation concealment (selection bias) | Low risk | Quote: "Random allocation (sealed envelope)" (p. 83) Comment: no mention of whether the envelopes were opaque or not, although they probably were |
| Blinding (performance bias and detection bias) | High risk | Quote: "The patients did not know whether they would be contacted at 4 and 8 months or not" (p. 83) Comment: The nature of this trial means that participants could have known to which group they had been allocated when they received the telephone call. |
| Blinding (performance bias and detection bias) | High risk | Comment: As telephone interventions were made by therapists, personnel could not be blinded to treatment allocation. |
| Blinding (performance bias and detection bias) | Unclear risk | Quote: "[A]ll study participants were interviewed again after 12 months at a personal meeting" (p.84). Comment: It is unclear if outcome assessors conducted these meetings and, if so, whether they were blinded to treatment allocation or not. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "An intent‐to‐treat analysis was performed on all patients who were followed up (n = 178) and the results were the same as in those 172 patients who got at least one intervention" (p.86). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: random numbered lists stratified for sex and admitting hospital; constructed independently of research team; administrator provided clinician with allocation by telephone after patient details given Follow‐up period: 12 months N lost to follow‐up: 0/467 (0%) for repetition data | |
| Participants | Inclusion criteria: i) resident in catchment area; ii) aged 16 years or older; iii) not aged 16‐19 years and still in full‐time secondary education; iv) overdoses did not include recreational or problematic substance use Exclusion criteria: i) aged less than 16 years; ii) aged between 16‐19 years and still enrolled in full‐time secondary education; iii) overdose episode occurred as the result of recreational or problematic substance use. Numbers: Of the 467 participants, 220 were allocated to the experimental arm and 247 to the control arm. Profile: 56% (n = 263) were female, 47% (n = 104) were repeaters, 17% (n = 80) had a history of psychiatric treatment, 13% (n = 60) had alcohol problems, and 3% (n = 12) were diagnosed with schizoaffective disorder Source of participants: patients presenting to hospital for SH Location: East London and Essex, UK | |
| Interventions | Experimental: case management involving psychosocial assessment, a negotiated care plan, and 'open access' to case manager who helped patient identify and access suitable services in addition to usual care Control: usual care involving triage, and medical and psychosocial assessment and treatment as required Therapists: assessing researchers, case managers or both Type of therapy offered: case management Length of treatment: up to 6 months, reviewable | |
| Outcomes | Included: i) repetition of SH according to hospital admission records; ii) suicide Excluded: none | |
| Notes | Sources of funding: "Funded by the participating health authority" (p. 167) Declaration of author interests: no details on author interests provided Other: data on suicides obtained following correspondence with authors | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Randomisation was conducted using random numbered lists, stratified for sex and admitting hospital. . . The researchers were required to telephone an administrator with possible candidates' details and were then informed of the treatment group" (p. 169) Comment: Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "The random number lists were constructed independently of the research team and they did not have sight of them." "The researchers were required to telephone an administrator with possible candidates' details and were then informed of the treatment group" (p. 169) |
| Blinding (performance bias and detection bias) | High risk | Quote: "Case management as deployed in the trial comprised a psychosocial assessment, a negotiated care plan and 'open access' to the assessing researcher (the case manager) via a dedicated (mobile) telephone contact number" (p. 169) Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Case management as deployed in the trial comprised a psychosocial assessment, a negotiated care plan and 'open access' to the assessing researcher (the case manager) via a dedicated (mobile) telephone contact number" (p. 169) Comment: As the intervention was delivered by therapists, personnel could not be blinded to treatment allocation. |
| Blinding (performance bias and detection bias) | Low risk | Comment: Authors report no details on blinding of outcome assessors. However, as readmission rates were the primary outcome and other adverse outcomes during follow‐up were assessed from A&E records, it would not appear that blinding of outcome assessors would have been problematic. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Data analysis proceeded on an intention to treat basis using the unpaired t test procedure, Yates corrected chi‐square and univariate and multivariate logistic regression. The analysis was carried out with SPSS 9 for Windows" (p. 170) Comment: In addition, the trial profile provided on p. 171 does not suggest there were any dropouts, as all patients were followed up at 12 months via A&E records. |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a random numbers table and delivered using prepared, sealed, opaque envelopes Follow‐up period: 6 months N lost to follow‐up: 0/103 (0%) for repetition of SH; 65/103 (63.1%) for secondary outcomes not included in this review (e.g., alcohol consumption, mental health problems, and satisfaction with treatment) | |
| Participants | Inclusion criteria: i) aged 18 or older; ii) admitted to an emergency department following an episode of SH; iii) diagnosed with alcohol misuse according to scores on the Paddington Alcohol Test Exclusion criteria: i) unwilling to provide informed consent; ii) unable to provide informed consent (e.g., due to an inability to communicate in English or impaired consciousness); iii) no fixed address in the greater London area; iv) already receiving treatment from alcohol misuse services; v) made a specific request to receive treatment from alcohol misuse services at index presentation Numbers: Of the 103 participants, 51 were allocated to the experimental arm and 52 were allocated to the control arm. Profile: 48.5% (n = 50) were female, 100% (n = 103) were diagnosed with alcohol misuse Source of participants: consecutive admissions to an emergency department following an episode of SH and who were diagnosed with alcohol misuse according to scores on the Paddington Alcohol Test Location: London, UK | |
| Interventions | Experimental: a one‐off appointment with an alcohol nurse specialist involving assessment and discussion of both current and previous drinking behaviours delivered according to the FRAMES approach in addition to a health information leaflet advising on the damaging effects of excessive alcohol consumption, recommended limits of alcohol consumption, and the contact details of nationally‐based alcohol misuse help lines (Miller 1993). Participants could also be referred by the alcohol nurse specialist to individual alcohol counselling or detoxification services as required. Control: TAU involving a health information leaflet advising on the damaging effects of excessive alcohol consumption, recommended limits of alcohol consumption, and the contact details of nationally‐based alcohol misuse help lines Therapist: 1 alcohol nurse specialist Type of therapy offered: alcohol‐specific therapy Length of treatment: approximately 30 minutes | |
| Outcomes | Included: i) repetition of SH; ii) suicide Excluded: i) alcohol consumption; ii) alcohol involved in SH episode; iii) diagnosis of probably personality disorder; iv) satisfaction with treatment | |
| Notes | Sources of funding: "This study was funded by St Mary's Paddington Charitable Trust" (p. 1827). Declaration of author interests: none stated Other: Data on suicides were obtained following correspondence with authors. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "We used simple randomization with an experimental to control treatment ratio of 1:1. . . using random numbers tables" (p. 1822). Comment: Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "Sealed opaque envelopes" (p. 1822) Comment: Use of sealed opaque envelope containing either an appointment card or a blank piece of card would ensure adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: This was a single‐blind study and only "researchers collecting follow‐up data were masked to allocation status" (p. 1825), suggesting that participants were not blind to allocation status. |
| Blinding (performance bias and detection bias) | High risk | Comment: This was a single‐blind trial and only "researchers collecting follow‐up data were masked to allocation status" (p. 1825), suggesting that personnel were not blind to allocation status. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "[R]esearchers collecting follow‐up data were masked to allocation status" (p. 1825). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Our primary analysis [repetition of SH] was conducted using an intention‐to‐treat principle" (p.1823). |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a random numbers table Follow‐up period: 3 months N lost to follow‐up: 6/20 (30.0%) at the 3 month follow‐up period | |
| Participants | Inclusion criteria: i) aged 18‐65 years; ii) diagnosed with any personality disorder according to the SCID‐II; iii) score 3 or greater on the Standardised Assessment of Personality Abbreviated Scale Exclusion criteria: i) unable to provide informed consent Numbers: Of the 20 participants, 14 were allocated to the experimental arm and 6 to the control arm. Profile: 100% (n = 20) were diagnosed with a personality disorder; 45.0% (n = 9) were diagnosed with comorbid substance misuse Source of participants: patients admitted to the medical receiving ward of the A&E department following an episode of SH Location: Glasgow, UK | |
| Interventions | Experimental: manualised cognitive therapy involving psycho‐education to help participants understand SH, potential alternatives to resolving problems, and referral to appropriate mental health services where required Control: TAU involving referral to community mental health teams, appointments with psychiatrists and a community psychiatric nurse, and inpatient psychiatric treatment as required Therapist: 2 therapists: 1 doctoral‐level clinical psychologist and 1 psychiatrist who received weekly training in manualised cognitive therapy Type of therapy offered: cognitive behavioural therapy Length of treatment: no details on length of treatment were provided | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iii) suicidal ideation; iv) depression Excluded: i) alcohol use; ii) anxiety and depression severity | |
| Notes | Source of funding: "This work was supported by NHS Greater Glasgow and the Scottish Mental Health Research Network" (p. 4). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Patients were randomised. . . using a random numbers table with an allocation of 2:1 in favour of [the intervention]" (p.2). Comment: Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation sequence provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The research assistant, who assessed patients at baseline and outcome, remained masked to treatment allocation throughout the study" (p. 2). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "[T]he intention‐to‐treat principle [was] applied, i.e. analyses [were] based on the initial treatment intent, not on the treatment eventually administered" (p. 2). |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on repetition of SH and depression from authors, suggesting that selective reporting bias may have been present. |
| Other bias | High risk | Comment: This was a very small trial with substantial imbalances between intervention and control groups with respect to levels of non‐suicidal self‐harm, anxiety, and depression at baseline. Follow‐up analyses did not adjust for these baseline imbalances. This is likely to result in exaggerated treatment effects as, in all cases, the control group had higher levels of self‐harm, anxiety, and depression. |
| Study characteristics | ||
| Methods | Allocation: random assignment using an unknown method Follow‐up period: 12 months N lost to follow‐up: 18/102 (17.6%) for repetition of SH data | |
| Participants | Inclusion criteria: i) attended emergency department following a suicide attempt; ii) aged 15‐34 years Exclusion criteria: i) hospitalised for more than 24 hours; ii) currently being treated by a psychiatrist Numbers: Of the 102 participants, 51 were randomised to the experimental arm and 51 to the control arm. Profile: 80% (n = 82) female Source of participants: patients attending emergency department Location: Bohars, France | |
| Interventions | Experimental: Brief psychotherapy involving 5 sessions during first month following the index episode. These sessions followed a specific therapeutic model. Control: TAU involving an assessment by a clinical psychiatrist. Upon leaving, these participants were followed‐up by a psychiatrist or psychologist. Therapists: participants continued to receive treatment from the same therapist who initially saw them at hospital Type of therapy offered: brief psychotherapy Length of treatment: 1 month | |
| Outcomes | Included: i) repetition of SH according to unknown source; ii) suicide Excluded: i) compliance | |
| Notes | Source of funding: no details on funding provided Declaration of author interests: no details provided Other: As compliance data were not reported for the control group, this outcome had to be excluded from subsequent analyses. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Two groups, with 51 patients each, [were] distributed by randomisation" (p. 557). Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: No details on allocation concealment are reported. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Quote: "Patients were evaluated by a clinician different to their therapist (translation)" (p. 558). Comment: However, it is not stated whether this clinician was blind to treatment allocation. |
| Incomplete outcome data (attrition bias) | High risk | Comment: Of the 70 participants, 34 refused to attend follow‐up and 12 were lost to follow‐up (could not be found). No further reasons for dropouts given. The authors, in addition, note that less than 2/3 of patients attended all 3 appointments. Despite this, they did not attempt ITT analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a sealed envelope which contained either an emergency green card or a 'dummy' card Follow‐up period: 12 months N lost to follow‐up: 0/827 (0%) for repetition data | |
| Participants | Inclusion criteria: i) admitted to emergency departments following an episode of SH; ii) referred for routine psychiatric evaluation; iii) resident in catchment area; iv) judged likely to use intervention appropriately; v) made contact with and used mental health services; vi) acceptable level of aggressive behaviour Exclusion criteria: i) inappropriate substance abuse leading to repetitive presentation in which the participant was aggressive or unable to engage in treatment Numbers: Of the 827 participants, 417 were allocated to the experimental arm and 410 to the control arm. Profile: 55.4% (n = 458) female, 42% (n = 349) were multiple repeaters Source of participants: patients admitted to general hospital following SH episode Location: Bristol, UK | |
| Interventions | Experimental: emergency card in addition to TAU. Participants were provided with an emergency card offering 24‐hour service for crisis telephone consultation with an on‐call psychiatrist. Control: TAU Therapist: on‐duty trainee psychiatrist Type of therapy offered: emergency card offering 24‐hour service for crisis telephone consultation with an on‐call psychiatrist in addition to TAU Length of treatment: 6 months | |
| Outcomes | Included: i) repetition of SH according to A&E and hospital admissions records; ii) suicide Excluded: none | |
| Notes | Sources of funding: "Funding was provided by a grant from the Department of Health" (p. 23) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Randomised on a 1:1 basis. . . using the sealed envelope technique" (p. 23) Comment: although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Low risk | Quote: "Randomised. . . using the sealed envelope technique, ensuring that it was impossible to tell from feeling or looking at the envelopes whether they contained a green card or a 'dummy card' (which was not given out)" (p. 23) Comment: Use of opaque sealed envelope containing either a green card or a 'dummy' card would ensure adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Those randomised to receive a green card were offered the card immediately after the psychiatric assessment" (p. 23) Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that personnel (e.g., GPs and psychiatrists on telephone duty) are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "All subjects' repeat hospital attendances for SH within 6 months of randomisation were monitored (blind to their study group) by means of a computerised case register based on routine accident and emergency admission data" (p. 24) |
| Incomplete outcome data (attrition bias) | Low risk | Quote: ". . . all analyses were conducted on an intention‐to‐treat basis." (p. 24) |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomised using opaque sealed envelopes opened sequentially Follow‐up period: 6 months N lost to follow‐up: 2/34 (6%) for repetition data | |
| Participants | Inclusion criteria: i) personality disturbance (antisocial, dissocial, impulsive or borderline); ii) at least 1 episode of SH in 12 months preceding entry to trial Exclusion criteria: i) diagnosed with alcohol or drug dependence, schizophrenia, or organic psychiatric disorder Numbers: Of the 34 participants, 18 were allocated to the experimental arm and 16 to the control arm. Profile: 62% (n = 21) were female, 100% (n = 34) were repeaters, 100% (n = 34) had a diagnosis of a personality disorder Source of participants: patients admitted after an episode of SH to 1 of 2 hospitals in the London area (Paddington and Chelsea, Westminster) Location: London, UK | |
| Interventions | Experimental: 2‐6 sessions of manual assisted cognitive behavioural therapy including basic cognitive techniques, problem‐solving, techniques for managing emotions and thoughts, and relapse prevention plans in individuals with personality disorders Control: TAU. 5 participants had contact with a psychiatrist, 3 saw a community mental health team, 4 saw a specialist social worker, and 2 saw no mental health professional Therapist: 1 psychiatrist, 2 nurses, and 2 social workers. The type of therapy recieved by the remaining 2 participants in the control group was not specified. Type of therapy offered: cognitive behavioural therapy Length of treatment: varied | |
| Outcomes | Included: i) repetition of SH according to self‐report and hospital records; ii) depression; iii) compliance Excluded: i) time to repetition of SH; ii) cost of care; iii) social functioning; iv) anxiety | |
| Notes | Sources of funding: "This work was supported by a grant from the North Thames Regional Health Authority" (p. 24) Other: 5 participants in the experimental group did not see a therapist and instead received therapy from the booklets. 1 participant in the experimental group did not receive any intervention. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Patients were allocated by opening opaque sealed envelopes sequentially at each centre" (p. 20). Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Low risk | Quote: "Patients were allocated by opening opaque sealed envelopes sequentially at each centre" (p. 20) Comment: Use of opaque sealed envelope would have ensured adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that personnel (a psychiatrist, 2 nurses and 2 social workers) would not have been blinded to the type of treatment they were giving. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Baseline assessments, before randomization, and follow‐up assessments, at 6 months, were completed by an independent assessor, who had no contact with the clinical teams during the trial and made assessments without any knowledge of treatment received" (p. 20). |
| Incomplete outcome data (attrition bias) | Low risk | Comment: Of the 34 participants, 2 dropped out after initial assessment and randomisation but "prior to knowledge of treatment allocation". They were subsequently excluded from all analyses, which the authors felt was appropriate, as no service had been provided to them following the initial assessment. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: random number table using opaque sealed envelopes Follow‐up period: 18 months N lost to follow‐up: 204/1867 (11%) for repetition data | |
| Participants | Inclusion criteria: i) diagnosis of self‐harm/self‐poisoning by medical staff Exclusion criteria: i) died on the ward; ii) presence of clinical conditions which would disallow interview; iii) left hospital against medical order; iv) resident in a different catchment area; v) had language difficulties Numbers: Of the 1867 participants, 922 were allocated to the experimental arm and 945 to the control arm. Profile: 58% (n = 1086) were female Source of participants: patients presenting to emergency care settings following an episode of self‐harm/self‐poisoning within a defined catchment area with a population of at least 250,000 Location: Brazil, India, Sri Lanka, Iran, and China | |
| Interventions | Experimental: brief cognitive behavioural intervention involving "information about suicidal behaviour as a sign of psychological and/or social distress, risk and protective factors, basic epidemiology, repetition, alternatives to suicidal behaviours, and referral options" (p. 705) and contact via telephone or home visits to provide referral support in addition to TAU Control: TAU "according to the norms prevailing in the respective emergency departments" (p. 704). This typically involved only acute treatment for somatic problems only. Therapist: clinician (e.g., psychiatrist, nurse, doctor) Type of therapy offered: information and support Length of treatment: 18 months | |
| Outcomes | Included: i) repetition; ii) suicide Excluded: i) compliance; ii) depression; iii) hopelessness; iv) impulsiveness; v) social support; vi) suicidal intent; vii) anger; viii) well‐being | |
| Notes | Sources of funding: "The study was funded by the Department of Mental Health and Substance Abuse, WHO. Some field research sites obtained additional funding from the following agencies: Campinas: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant no 02/08288‐9, São Paulo, Brazil; Durban: Medical Research Council (MRC), Tygerberg, Cape Town, South Africa; Karaj: Tehran Psychiatric Institute, Mental Health Research Centre (IUMS), Tehran, Iran; Tallinn: Estonian Health Insurance Fund, Tallinn, Estonia; the Swedish National and Stockholm County Centre for Suicide Research and Prevention of Mental Ill‐Health (NASP), WHO Colloborating Centre for Research and Training in Suicide Prevention, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden" (p. 708). Declaration of author interests: none stated Other: We obtained data on repetition of SH and suicides following correspondence with authors. Excluded outcomes are taken from the trial protocol. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "An allocation sequence based on a random‐number table was used to randomly assign all enrolled subjects" (p. 704) Comment: Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: ". . . the allocation sequence was maintained in a separate location to prevent clinician bias" (p. 704) |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The subjects were blinded as to their assignment" (p. 704) |
| Blinding (performance bias and detection bias) | High risk | Comment: No details on personnel blinding are provided; however, the nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: No details on outcome assessor blinding are provided. |
| Incomplete outcome data (attrition bias) | High risk | Comment: Authors report the number of participants lost to follow‐up; however, they did not provide reasons for dropout, nor did they attempt to use intention‐to‐treat analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: Authors collected additional outcome information, including adherence, depression, hopelessness, impulsiveness, social support, suicidal intent, anger, and well‐being. They did not reportit, but they report some of these outcomes in related trials (i.e., Hassanzadeh 2010; Vijayakumar 2011; Xu 2012). |
| Other bias | Low risk | Comment: no apparent sources of other bias |
| Study characteristics | ||
| Methods | Allocation: Correspondence with authors confirmed that participants were randomly assigned using sequentially numbered, sealed, opaque envelopes. Follow‐up period: 12 months N lost to follow‐up: 0/400 (0%) for repetition data | |
| Participants | Inclusion criteria: i) over 17 years old Exclusion criteria: i) immediate suicide risk; ii) no formal psychiatric illness Numbers: Of the 400 participants, 200 were allocated to the experimental arm and 200 to the control arm. Profile: Self poisoning patients, including both multiple repeaters and first‐timers. 71% (n = 284) were female, 44% (n = 176) were diagnosed with depressive neurosis, 2% (n = 8) with phobic neurosis, 2% (n = 8) with affective psychosis, and 1% (n = 4) with schizophrenia Source of participants: patients presenting to an A&E department following an episode of deliberate self‐poisoning Location: Southampton, UK | |
| Interventions | Experimental: crisis‐oriented, time‐limited, task‐centred social work provided at home, which included problem‐solving intervention for personal relationships, emotional distress, practical problems, etc. Control: TAU. 54% (n = 108) were referred to their GP, 33% (n = 66) received a psychiatric referral, and 13% (n = 26) received an unspecified referral. Therapist: 2 social workers Type of therapy offered: task‐centred case management alongside problem‐solving therapy Length of treatment: 3 months | |
| Outcomes | Included: i) repetition of SH according to hospital records; ii) depression; iii) social problems Excluded: i) satisfaction with service | |
| Notes | Sources of funding: "The study was supported by the Department of Health and Social Security, and the Wessex Regional Health Authority" (p. 117) Declaration of author interests: no details on author interests were provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Comment: Correspondence with authors confirmed that participants were randomly assigned using sequentially numbered, sealed, opaque envelopes. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors confirmed that participants were randomly assigned using sequentially numbered, sealed, opaque envelopes. Use of opaque sealed envelope would have ensured adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: No details on personnel blinding are provided; however, the nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The follow‐up interviews were carried out by three experienced interviewers. . . [who] had had no connection with the project and did not know what treatment patients had received" (pp. 113‐114) Comment: Additionally, reliability between outcome assessors was also assessed on p. 116. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: ". . . there were no differences in age and sex distribution between the interviewed sample and the missing cases" (p. 114). Comment: Given there were no difference in age and sex distribution between the interviewed and missing cases, missing data were unlikely to have affected the outcome. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: random assignment using an unknown method Follow‐up period: 14 weeks N lost to follow‐up: 2/24 (8%) for repetition data | |
| Participants | Inclusion criteria: i) diagnosis of borderline personality disorder; ii) history of deliberate self‐harm, with at least 1 episode in the past 6 months; iii) have an individual therapist; iv) aged 18 to 60 years; v) female Exclusion criteria: i) diagnosis of a psychotic disorder, bipolar I disorder, or substance dependence; ii) suicide attempt rated as having a 'high' risk of death or greater within past 6 months; iii) at risk of attempting suicide within the next year; iv) received dialectical behaviour therapy in the past 6 months Numbers: Of the 24 participants, 13 were allocated to the experimental arm and 11 to the control arm. Profile: 100% (n = 24) were female, 100% (n = 24) were multiple repeaters Source of participants: clinician referrals and self referrals from advertisements posted at a hospital and on 2 websites Location: Boston, MA, USA | |
| Interventions | Experimental: weekly emotion regulation group intervention and individual therapy sessions in addition to TAU Control: TAU, including individual therapy sessions Therapists: group and individual emotion regulation therapists Type of therapy offered: emotion regulation group intervention Length of treatment: 14 weeks | |
| Outcomes | Included: i) repetition of SH according to self report; ii) depression Excluded: i) emotion regulation; ii) emotional avoidance; iii) impairment due to BPD; iv) anxiety; v) stress | |
| Notes | Sources of funding: "This research was supported by the Psychosocial Fellowship of McLean Hospital, awarded to the first author" (p. 25). Declaration of author interests: Although no details on author interests were provided, Prof Gratz developed emotion regulation group therapy. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: ""Random assignment" (p. 30) Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: No details on allocation concealment were provided. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Research team members were not blind to condition" (p. 30). |
| Incomplete outcome data (attrition bias) | High risk | Quote: "Two participants dropped out of the study (one from each condition)" (p. 27) Comment: Despite this, authors did not attempt ITT analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: stratified randomisation procedure matching for i) emotion dysregulation; ii) number of lifetime episodes of SH; iii) Global Assessment of Functioning scores; iv) age Follow‐up period: 3 and 9 months N lost to follow‐up: 12/61 (23.5%) | |
| Participants | Inclusion criteria: i) females; ii) aged 18‐60 years; iii) diagnosed with threshold or subthreshold borderline personality disorder; iv) history of repeated SH with at least 1 episode in the past 6 months; v) have one or more of the following: individual therapist, psychiatrist, case manager Exclusion criteria: i) diagnosed with psychosis or bipolar I disorder; ii) current (past month) substance use Numbers: Of the 61 participants, 31 were allocated to the intervention arm and 30 to the control arm. Profile: 100% (n = 61) were female; 100% (n = 61) were multiple repeaters; 62.3% (n = 38) had previously made a suicide attempt; 50.0% (n = 31) were diagnosed with any mood disorder; 62.3% (n = 38) were diagnosed with an anxiety disorder; 36.0% (n = 22) were diagnosed with PTSD; 13.3% (n = 8) were diagnosed with an eating disorder; 1.6% (n = 1) were diagnosed with substance use disorder. Source of participants: referrals from clinicians to the emotion regulation group therapy and from self referrals in response to an advertisement posed both online and in the community Location: Jackson, MS, USA | |
| Interventions | Experimental: emotion‐regulation group therapy involving psycho‐education to develop awareness, understanding, and acceptance of emotions, the ability to engage in goal‐directed behavior whilst inhibiting impulsive behaviours without experiencing negative emotions, use of situationally appropriate strategies to moderate either the intensity or duration of emotions, and the willingness to experience some negative emotions as a consequence of daily life Control: TAU involving outpatient treatment with individual therapists. Some participants also received group therapy as part of TAU, although this was not emotion‐regulation group therapy. Therapist: 2 doctoral‐level therapists who received at least 4 months of training in delivering emotion‐regulation group therapy Type of therapy offered: emotion‐regulation group therapy Length of treatment: 14 weeks | |
| Outcomes | Included: i) repetition of SH; ii) depression | |
| Notes | Sources of funding: "This research was supported by National Institute of Mental Health Grant R34 MH079248, awarded to Dr. Gratz" (p. 2110). Declaration of author interests: Although no details on author interests were provided, Prof Gratz developed emotion‐regulation group therapy. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Participants . . . were matched on four prognostic variables [emotion dysregulation, number of lifetime incidents of SH, global assessment of functioning (GAF) scores, and age] and randomly assigned. . . using a stratified randomization procedure" (p. 2100). Comment: although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: No details on allocation concealment were provided. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "All assessments were conducted by trained assessors masked to participant condition" (p. 2103). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "We adopted a Bayesian approach . . . using the Markov chain Monte Carlo routines . . . This approach implements a multiple imputation strategy to handle missing data. . . enabling an analysis of the intent‐to‐treat (ITT) sample" (p. 2104). |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: After consent, recruiting member of research team referred to an allocation sequence provided by the trial statistician and based on a computer‐generated list of random numbers to assign participants. Follow‐up period: 6 months N lost to follow‐up: 0/119 (0%) for repetition data | |
| Participants | Inclusion criteria: i) aged 18‐65 years; ii) presenting with episode of deliberate self‐poisoning; iii) able to read and write English; iv) living in the catchment area of the hospital; v) registered with a GP Exclusion criteria: i) requiring psychiatric treatment Numbers: Of the 119 participants, 58 were allocated to the experimental arm and 61 to the control arm. Profile: 55.5% (n = 66) were female, 60% (n = 71) were multiple repeaters, 55% (n = 65) had a history of psychiatric treatment. Source of participants: patients presenting to hospital after deliberate self‐poisoning Location: Manchester, UK | |
| Interventions | Experimental: weekly 50‐minute sessions of an individual home‐based psychodynamic interpersonal therapy involving identification of personal difficulties. Participants were left to resolve interpersonal difficulties causing distress through a conversational approach focused on the identification of feelings and relating these to problems and relationships to develop shared understanding and approaches to family problems. Control: TAU. In most cases this involved assessment by doctor in the emergency department and referral to psychiatry outpatient treatment, addiction services, or GP Therapists: nurse therapists Type of therapy offered: psychodynamic interpersonal therapy Length of treatment: 4 weeks | |
| Outcomes | Included: i) repetition of SH according to self report and hospital records; ii) suicide; iii) suicidal ideation; iv) depression Excluded: i) patient satisfaction | |
| Notes | Sources of funding: "North West Regional Health Authority and the NHS Research and Development Levy" (p. 4). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "block randomised design" (p. 5). Comment: Correspondence with the authors further clarified that after consent, recruiting member of research team referred to an allocation sequence, provided by the trial statistician and based on a computer‐generated list of random numbers to assign participants in groups of 12 participants (stratified according to whether or not participants had a history of SH). Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors clarified that allocation was concealed from the recruiting member of the research team. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel (e.g., nurse therapists, GPs) are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Follow up assessments were conducted by one of two research assistants, who were blind to treatment groups" (p. 2) Comment: Data on repetition of SH, however, were obtained from participant self report. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: " [W]e included in the analysis all patients who completed the assessments at the end of treatment or at six month follow up assessments. Comparisons between groups were made on an intention to treat basis" (p. 2). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a minimisation procedure matched for: i) number of suicide attempts in the past year; ii) number of episodes of NSSI in the past year; iii) PTSD symptom severity; iv) dissociation symptom severity; v) current use of any SSRI medication Follow‐up period: 3 months N lost to follow‐up: 8/26 (30.8%) | |
| Participants | Inclusion criteria: i) female; ii) aged 18‐60 years; iii) diagnosed with borderline personality disorder; iv) diagnosed with post‐traumatic stress disorder (PTSD); v) satisfactory recall of at least part of the index trauma; vi) recent and recurrent engagement in SH (at least 2 suicide attempts or episodes of NSSI in the previous 5 years with at least 1 occurring within the past 8 weeks); vii) lives within commuting distance of the specialist clinic Exclusion criteria: i) diagnosed with psychosis, bipolar disorder, or mental retardation; ii) receiving treatment under a legal mandate; iii) require treatment for another life‐threatening condition (e.g., anorexia nervosa) Numbers: Of the 26 participants, 19 were allocated to the intervention arm and 7 were allocated to the control arm. Profile: 100% (n = 26) were female; 100% (n = 26) were diagnosed with borderline personality disorder; 100% (n = 26) were diagnosed with PTSD. Source of participants: patients seeking treatment from a specialist treatment service for suicidal individuals with comorbid borderline personality disorder and PTSD, flyers, and from outreach services within the catchment area. Location: Seattle, WA, USA | |
| Interventions | Experimental: dialectical behaviour therapy with the prolonged exposure protocol involving individual psychotherapy, group skills training, phone consultations as required, and weekly therapist consultation sessions. The prolonged exposure protocol enabled participants to receive longer individual therapy sessions per week. Control: dialectical behaviour therapy involving individual psychotherapy, group skills training, phone consultations as required, and weekly therapist consultation sessions Therapists: masters' level clinicians with an average of 2 years of clinical experience. Most were doctoral‐level students in training (52.6%), followed by licensed professionals (36.8%), and postdoctoral fellows (10.5%). Clinicians had received training in DBT for at least 1 day. Type of therapy offered: dialectical behaviour therapy with the prolonged exposure protocol Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicides; iii) suicide attempts; iv) depression; v) compliance | |
| Notes | Source of funding: "This work was supported by grant R34MH082143 from the National Institute of Mental Health" (p. 16). Declaration of author interests: "Drs. Harned, Korslund, and Linehan are trainers and consultants for Behavioral Tech, LLC" (p. 16). | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "A minimization randomization procedure was used to match participants on the five primary prognostic variables: (1) number of suicide attempts in the last year; (2) number of NSSI episodes in the last year; (3) PTSD severity; (4) dissociation severity; and (5) current use of SSRI medication" (pp. 8‐9). Comment: Use of a minimisation randomisation algorithm is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors clarified that allocation was concealed from assessors as randomisation was completed by a staff member not involved in assessments. Furthermore, there was no way to foresee the outcome of the randomisation algorithm. |
| Blinding (performance bias and detection bias) | High risk | Comment: Correspondence with authors clarified that allocation was concealed from participants until their first therapy session, at which point their therapist informed them as to which treatment condition they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: Correspondence with authors clarified that allocation was concealed from participants until their first therapy session, at which point their therapist informed them as to which treatment condition they had been allocated, suggesting that personnel were aware of which participant had been allocated to which treatment condition. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "[A]ssessments were conducted by independent clinical assessors who were blind to treatment condition" (p. 9). |
| Incomplete outcome data (attrition bias) | Low risk | Comment: both intention‐to‐treat and per protocol analyses provided |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a block randomisation procedure using a random digit table. Follow‐up period: 12 months N lost to follow‐up: 187/2300 (8.1%) for repetition of SH at 12 months | |
| Participants | Inclusion criteria: i) aged 12 or older; ii) admitted or transferred to a specialist hospital for the treatment of poisoning following an episode of deliberate self‐poisoning Exclusion criteria: i) treated in the emergency department of a regular hospital; ii) diagnosed with psychosis; iii) unable to provide informed consent (e.g., unable to communicate in Farsi); iv) of no fixed address; v) potential threat to interviewers; vi) episode of self‐poisoning was classified by the attending toxicologist as recreational, habitual, accidental, or iatrogenic. Numbers: Of the 2300 participants, 1150 were allocated to the experimental arm and 1150 to the control arm. Profile: 66.4% (n = 1402) were female, 31.4% (n = 723) were multiple repeaters. Source of participants: patients admitted or transferred to a specialist hospital for the treatment of poisoning following an episode of deliberate self‐poisoning Location: Tehran, Iran | |
| Interventions | Experimental: postcards mailed at 1, 2, 3, 4, 6, 8, 10, and 12 months after discharge in addition to TAU Control: TAU. Although no specific details are provided, the authors note that "[f]ollow‐up care for self‐poisoning in Tehran is generally poor. . . Contact is mainly hospital‐ or office‐based, and community‐based programs are almost non‐existent. Psychiatric beds are often at 100% occupancy, with short admissions and frequent readmissions." (pp. 310‐311). Therapist: none Type of therapy offered: outreach through the mailing of frequent postcards encouraging participants to make contact with the service Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH according to self report; ii) suicide; iii) suicide attempts according to self report cross‐validated against hospital records; iv) suicidal ideation Excluded: ii) number receiving postcard; ii) number finding postcard helpful in the prevention of SH; iii) death from any cause | |
| Notes | Sources of funding: "This study was supported by a grant from the Legal Medicine Organization of Iran and the Loghman‐Hakim Research Development Unit, Shahid Beheshti Medical University" (p. 315). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Block randomisation (blocks of 100) was undertaken using a random digit table" (p. 310). Comment: the authors note that although " . . . this older form of randomisation is potentially liable to interference. . . no imbalances at baseline suggest that the randomisation was likely to have been successful" (p. 314). |
| Allocation concealment (selection bias) | Low risk | Quote: "To maintain masking to allocation, randomisation was not revealed to the recruiting toxicologist until all information was entered and eligibility determine" (p. 310). |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Other staff were masked to allocation status during hospital treatment" (p. 310). |
| Blinding (performance bias and detection bias) | High risk | Quote: "The research psychologist was not masked to allocation status at follow‐up" (p. 310). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All outcomes were analysed on randomisation status at baseline for 12‐month follow‐up" (p. 311). |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to obtain data on suicides following correspondence with authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation based on Zelen's method using a computer‐generated numbers list Follow‐up period: 12 months for primary outcome (i.e., repetition of SH) and 3 and 12 months for secondary outcomes (i.e., suicidal ideation, depression, hopelessness, and problem‐solving) N lost to follow‐up: 158/1094 (14.4%) by the 1‐year follow‐up period | |
| Participants | Inclusion criteria: i) 16 years or older; ii) admitted to hospital following an episode of SH Exclusion criteria: i) still enrolled full time in school; ii) currently receiving dialectical behaviour therapy for the treatment of borderline personality disorder; iii) had a treatment management plan which precluded receiving short‐term therapy; iv) cognitively impaired; v) admitted to a psychiatric care unit following the index episode of SH for a minimum period of 48 h Numbers: Of the 552 participants who provided informed consent, 253 were allocated to the experimental arm and 299 were allocated to the control arm. Profile: 68.8% (n = 380) were female, 44.7% (n = 247) were multiple repeaters Source: patients admitted to hospital following an episode of SH Location: Auckland and Wellington, New Zealand | |
| Interventions | Experimental: problem‐solving therapy based on D'Zurilla 1971 involving problem orientation, problem listing, definition, brainstorming of alternative solutions, devising an action plan, and reviewing the plan in addition to TAU Control: TAU involving a one‐off psychosocial assessment by a mental health professional Therapist: clinicians without extensive clinical experience working in the mental health care setting who received 1 week of training in problem‐solving therapy Type of therapy offered: problem‐solving therapy Length of treatment: 3 months | |
| Outcomes | Included: i) repetition of SH according to hospital records; ii) suicide; iii) suicidal ideation; iv) depression; v) hopelessness; vi) problem‐solving Excluded: i) anxiety | |
| Notes | Sources of funding: "This study was funded by the Accident Compensation Corporation of New Zealand" (p. 316). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "[P]atients were randomised (1:1) using computer‐generated random numbers. . . " (p. 311) Comment: Use of a computer‐generated list is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | High risk | Quote: "patients were randomised (1:1) using computer‐generated random numbers (from an independent statistician) contained in sealed envelopes" (p. 311) Comment: Use of opaque sealed envelope could have ensured that allocation was concealed; however, use of Zelen's design makes it unlikely that participants and clinical personnel would have remained unaware of allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: As consent was obtained using Zelen's method, participants were given the option to change treatment arms following allocation. Therefore, participants cannot have been blinded as to treatment allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Researchers masked to treatment allocation subsequently interviewed consenting participants by telephone" (p. 311) |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "For the primary outcome we could obtain information on repetition of self‐harm for everyone who was randomised, so the analysis . . . is a true intention‐to treat analysis. . . For the analysis of secondary outcomes we used data from just those people who consented to take part in the study and we have called this a per protocol analysis" (p. 312). Comment: mixture of intention‐to‐treat and per protocol analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: data on suicides had to be requested from authors, suggesting that selective reporting bias may have been present. |
| Other bias | High risk | Comment: Use of Zelen's design may have led to bias. |
| Study characteristics | ||
| Methods | Allocation: randomisation based on Zelen's method using a centrally generated randomisation sequence. A stratified minimisation procedure was also used to ensure balance in key prognostic factors (i.e., history of SH and method of SH) between the 4 sites Follow‐up period: 12 months for primary outcome (i.e., hospital recorded repetition of SH) and 3 and 12 months for secondary outcomes (i.e., self reported repetition of SH, depression, and hopelessness) N lost to follow‐up: 0/1474 (0%) for the primary outcome measure of hospital re‐presentations for SH. | |
| Participants | Inclusion criteria: i) presented to the emergency department at 1 of the 4 participating hospitals following an episode of SH Exclusion criteria: i) aged less than 17 years; ii) still enrolled full‐time in school; iii) unable to provide informed consent; iv) self identified as Māori (these participants were instead invited to participate in the Hatcher 2016a trial). Numbers: Of the 684 participants who provided informed consent, 327 were allocated to the experimental arm and 357 were allocated to the control arm. Profile: Of those who consented to participation 67.8% (n = 464) were female, 54.1% (n = 370) were multiple repeaters. Source: patients admitted to hospital following an episode of SH Location: Waitemata, Manukau, Northland, and Waikato regions, New Zealand | |
| Interventions | Experimental: 4‐6 sessions of problem‐solving therapy in the 4 weeks following the index SH episode; postcards mailed at 1,2,3,4,6,8,10 and 12 months following the index SH episode; 1‐2 face‐to‐face or telephone patient support sessions over the 2‐week period following discharge from hospital to ensure patients were adhering to their agreed discharge plan; improved access to primary care via the provision of a voucher that could be used to access 1 free GP consultation; development of a risk management strategy; and a cultural assessment focused on identifying patients' sense of belonging and identification with their ethnic group Control: TAU involving referral to multidisciplinary teams for psychiatric/psychological assessment, intervention, or both; referral to crisis teams; or referral to community‐based drug or alcohol treatment teams as necessary Therapist: research clinicians (no further details on qualifications or experience were provided), mental health crisis and community mental health clinicians (no further details on qualifications or experience were provided), GPs, and substance misuse counsellors (no further details on qualifications or experience were provided) Type of therapy offered: mixture of brief psychosocial therapy, telephone contact, and postal intervention Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iv) depression; v) hopelessness Excluded: i) anxiety; ii) quality of life; iii) sense of belonging; iv) ethnic identification | |
| Notes | Sources of funding: none stated Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "All eligible participants were allocated randomly to the intervention or usual care groups using a central computerised randomisation system at the Clinical Trials Research Unit (subsequently the National Institute for Health Innovation) . . . Stratified minimisation randomization was used to ensure a balance in key prognostic factors between the study groups" (p. 6 of the manuscript). Comment: Use of a computerised randomisation procedure is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | High risk | Quote: "[P]articipants were allocated randomly. . . using a central computerised randomisation system at the Clinical Trials Research Unit (subsequently the National Institute for Health Innovation)" (p. 6 of the manuscript). Comment: Use of offsite randomisation could have ensured that allocation was concealed; however, use of Zelen's design makes it unlikely that participants and clinical personnel would have remained unaware of allocation. |
| Blinding (performance bias and detection bias) | High risk | Quote: " [T]he introduction to the study differed depending on whether [the participant was] randomised to the control or intervention group" (p. 3 of the manuscript). Comment: As consent was obtained using Zelen's method, participants were given the option to change treatment arms following allocation. Therefore, participants cannot have been blinded as to treatment allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The research assistants were blind to treatment allocation" (p. 6 of the manuscript). |
| Incomplete outcome data (attrition bias) | Unclear risk | Quote: "Analysis of the primary outcome was in everyone who was randomised. . . The secondary outcomes were analysed only in those people who had consented to be in the study" (p. 6 of the manuscript). Comment: mixture of intention‐to‐treat and per protocol analyses |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | High risk | Comment: Use of Zelen's design may have led to bias. |
| Study characteristics | ||
| Methods | Allocation: randomisation based on Zelen's method using a centrally‐generated randomisation sequence. A stratified minimisation procedure was also used to ensure balance in key prognostic factors (i.e., history of SH and method of SH) between the 3 sites. Follow‐up period: 12 months for primary outcome (i.e., hospital recorded repetition of SH) and 3 and 12 months for secondary outcomes (i.e., self reported repetition of SH, depression, and hopelessness) N lost to follow‐up: 0/365 (0%) for hospital re‐presentations for SH. | |
| Participants | Inclusion criteria: i) presented to the emergency department at 1 of the 3 participating hospitals following an episode of SH; ii) self identified as Māori; iii) able to communicate effectively in Te Reo Maori (Māori language) Exclusion criteria: i) aged less than 17 years; ii) still enrolled full‐time in school; iii) unable to provide informed consent Numbers: Of the 167 participants who provided informed consent, 95 were allocated to the experimental arm and 72 were allocated to the control arm. Profile: Of those who consented to participation 65.3% (n = 109) were female, 59.9% (n = 100) were multiple repeaters. Source: patients admitted to hospital following an episode of SH Location: Waitemata, Manukau, and Northland regions, New Zealand | |
| Interventions | Experimental: a culturally sensitive treatment framework consisting of 4‐6 sessions of problem‐solving therapy in the 4 weeks following the index SH episode; postcards mailed at 1,2,3,4,6,8,10 and 12 months following the index SH episode, 1‐2 face‐to‐face or telephone patient support sessions over the 2 week period following discharge from hospital to ensure patients were adhering to their agreed discharge plan, improved access to primary care via the provision of a voucher that could be used to access 1 free GP consultation, development of a risk management strategy, and a cultural assessment focused on identifying patients' sense of belonging and identification with Māori culture Control: TAU involving referral to multi‐disciplinary teams for psychiatric/psychological assessment, intervention, or both; referral to crisis teams; or referral to community‐based drug or alcohol treatment teams as necessary Therapist: research clinicians (no further details on qualifications or experience were provided), mental health crisis and community mental health clinicians (no further details on qualifications or experience were provided), GPs, and addiction counsellors (no further details on qualifications or experience were provided) Type of therapy offered: mixture of brief psychosocial therapy, telephone contact, and postal intervention Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iv) depression; v) hopelessness Excluded: i) anxiety; ii) quality of life; iii) sense of belonging; iv) ethnic identification; v) cultural impact | |
| Notes | Sources of funding: none stated Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "All eligible participants were allocated randomly to the intervention or usual care groups using a central computerised randomization system at the Clinical Trials Research Unit (subsequently the National Institute for Health Innovation) . . . Stratified minimisation randomization was used to ensure a balance in key prognostic factors between the study groups" (p. 7 of the manuscript). Comment: Use of a computerised randomisation procedure is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | High risk | Quote: " [P]articipants were allocated randomly using a central computerised randomisation system at the Clinical Trials Research Unit (subsequently the National Institute for Health Innovation) . . . " (p. 7 of the manuscript). Comment: Use of offsite randomisation could have ensured that allocation was concealed; however, use of Zelen's design makes it unlikely that participants and clinical personnel would have remained unaware of allocation. |
| Blinding (performance bias and detection bias) | High risk | Quote: "[T]he introduction to the study differed depending on which arm of the trial [the participant was] randomised to" (p. 3 of the manuscript). Comment: As consent was obtained using Zelen's method, participants were given the option to change treatment arms following allocation. Therefore, participants cannot have been blinded as to treatment allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The research assistants were blind to treatment allocation" (p. 6 of the manuscript). |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: mixture of intention‐to‐treat and per protocol analyses. Hospital‐recorded episodes of repeated SH, for example, were available for all 365 participants who were enrolled, whereas data on outcomes measured on a continuous scale (e.g., depression, hopelessness) are available for the 167 participants who provided informed consent. |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | High risk | Comment: Use of Zelen's design may have led to bias. |
| Study characteristics | ||
| Methods | Allocation: random number method using sealed, opaque envelopes Follow‐up period: 12 months N lost to follow‐up: 0/96 (0%) for repetition of SH data | |
| Participants | Inclusion criteria: i) aged over 16 years; ii) suitable for randomisation (e.g., fixed abode) Exclusion criteria: i) in psychiatric care; ii) residing outside of catchment area; iii) requiring treatment for alcohol or dug addiction; iv) in need of inpatient psychiatric care Numbers: Of the 96 participants, 48 were allocated to the experimental arm and 48 to the control arm. Profile: 70% (n = 67) were female, 32% (n = 31) were multiple repeaters Source of participants: patients admitted to a general hospital following an episode of deliberate self‐poisoning Location: Oxford, UK | |
| Interventions | Experimental: domiciliary (home‐based) therapy, where the frequency of treatment sessions was flexible according to therapists' 'assessment of needs'. Open telephone access to the general hospital service was also available. Control: outpatient therapy once a week in an outpatient clinic in a general hospital Therapist: 2 junior psychiatrists, 1 psychiatric nurse, and 1 social worker Type of therapy offered: brief problem‐oriented psychological therapy Length of treatment: up to 3 months | |
| Outcomes | Included: i) repetition of SH according to hospital records, self report, and from a GP questionnaire; ii) compliance; iii) improvement in problems; iv) suicidal ideation Excluded: i) mood; ii) social adjustment; iii) GP questionnaire | |
| Notes | Sources of funding: "The project was supported by a grant from the Department of Health and Social Security" (p. 177). Declaration of author interests: no details on author interests provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "A random number method was used to select subjects" and "each patient was then allocated to 1 of the 2 treatment conditions by a randomized procedure" (p. 172) Comment: Use of a random numbers method is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors clarified that sealed, opaque envelopes were used to conceal allocation. Use of opaque sealed envelope would ensure adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The assessor remained blind to the treatment offered" (p. 172). |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: 6% of patients were not available for post‐treatment assessment and 15% were not available for 6‐month assessment. No further details on whether intention‐to‐treat analyses were undertaken are provided, however. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using opaque envelopes according to a random number table in blocks of 8 with equal allocation to the experimental and control arms Follow‐up period: 12 months N lost to follow‐up: 0/80 (0%) for repetition of SH data | |
| Participants | Inclusion criteria: i) aged over 16; ii) registered with a general practitioner; iii) living up to 15 miles away from hospital; iv) suitable for outpatient counselling; iv) willing to accept aftercare offered Exclusion criteria: i) in need of psychiatric care (day‐patient or inpatient); ii) currently in psychiatric care Numbers: Of the 80 participants, 41 were allocated to the experimental arm and 39 to the control arm. Profile: 66% (n = 53) were female, 31% (n = 25) were multiple repeaters Source of participants: patients admitted to a general hospital following an episode of self‐poisoning Location: Oxford, UK | |
| Interventions | Experimental: up to 8 sessions, each lasting on average 54 minutes, of outpatient problem‐solving therapy delivered by non‐medical clinicians Control: GP care including individual support, marriage counselling, psychiatric referral, etc. Therapist: 5 counsellors from clinical team in the general hospital psychiatric service Type of therapy offered: problem‐solving therapy Length of treatment: not stated | |
| Outcomes | Included: i) repetition of SH according to hospital records, self report, collateral informant report, or from interviews with the participants' GP; ii) suicide; iii) depression; iv) improvement in problems Excluded: i) social adjustment; ii) attitudes to treatment; iii) General Health Questionnaire; iv) GP interview; v) compliance | |
| Notes | Sources of funding: "This study was supported by a grant from the Medical Research Council" (p. 760). Declaration of author interests: no details on author interests provided Other: As compliance data were not reported for the control group, this outcome had to be excluded from subsequent analyses. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Patients were allocated by a randomized procedure" (p. 752). Comment: Correspondence with authors clarified that the allocation sequence was generated using a random number table in blocks or 8 with equal allocation to the experimental and control groups. Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors clarified that sealed, opaque envelopes were used to conceal allocation. Use of opaque sealed envelope would ensure adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Assessment interviews were conducted by research interviewers, who, until towards the end of the second follow‐up, remained blind to which treatment group the patients had been allocated" (p. 753). |
| Incomplete outcome data (attrition bias) | Low risk | Comment: combined use of hospital records and GP reports would enable information on all clinically treated SH episodes to be obtained, suggesting intention‐to‐treat analyses were undertaken. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computer‐generated allocation sequence Follow‐up period: 3 and 6 months N lost to follow‐up: 4/221 (1.8%) by the 3‐month follow‐up period; 8/221 (3.6%) by the 6‐month follow‐up period | |
| Participants | Inclusion criteria: i) aged 16‐64 years; ii) living within the catchment area of 1 of the 3 participating university hospitals Exclusion criteria: i) requiring inpatient psychiatric treatment; ii) temporarily resident in the catchment area of 1 of the 3 participating university hospitals; iii) diagnosed with a mental disorder due to a general medical condition, substance misuse, dementia, delirium, substance dependence, schizophrenia, bipolar disorder, or an intellectual disability according to DSM‐IV criteria. Numbers: Of the 221 participants, 108 were allocated to the intervention arm and 113 were allocated to the control arm. Profile: 68.8% (n = 152) were female; 4.1% (n = 9) were multiple repeaters Source of participants: patients admitted to the medical unit a university hospitals following an episode of SH Location: Karachi, Sindh province, Pakistan | |
| Interventions | Experimental: manualised culturally adapted problem‐solving therapy based on principles of cognitive behavioural therapy involving an evaluation of the SH attempt, development of crisis management skills, use of problem‐solving and cognitive‐behavioural techniques to improve emotion regulation skills, negative thinking, interpersonal relationships, and to improve relapse prevention strategies. Control: TAU. The authors further clarify that "[p]atients are not routinely referred to psychiatric or psychological services" (p. 464). Therapist: qualified, Masters‐level psychologists with a minimum of 3 years postqualification clinical experience. Clinicians also received training in delivering the intervention treatment. Type of therapy offered: problem‐solving therapy Length of treatment: 3 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iii) suicidal ideation; iv) depression; v) hopelessness; vi) problem‐solving; vii) compliance Excluded: i) quality of life; ii) help‐seeking behaviours; iii) days spent in inpatient treatment; iv) attendances at outpatient clinics; v) GP consultations; vi) consultations with any other doctors; vii) consultations with non‐medical religious healers; viii) consultations with non‐medical homeopathic healers | |
| Notes | Source of funding: "This study was jointly funded by the University of Manchester and Pakistan Institute of Learning and Living" (p. 469). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: " [A]n allocation sequence . . . was based on a computer‐generated list of random numbers. . . Randomisation was performed using www.randomization.com. Participants meeting the entry criteria were randomly allocated to each condition in a 1:1 ratio using permuted blocks of 6" (p.463). Comment: Use of a computer‐generated list is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: " [A]n allocation sequence. . . was provided by the off‐site statistician (independent of the research team)" (p. 463). |
| Blinding (performance bias and detection bias) | High risk | Quote: "It was not possible to keep the. . . participants themselves masked to the group allocation" (p. 463). |
| Blinding (performance bias and detection bias) | High risk | Quote: "It was not possible to keep the clinicians at participating centres. . . masked to the group allocation" (p.463). |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Research assistants [were] masked to treatment allocation" (p. 463). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Comparisons between groups were made on an intention‐to‐treat basis" (p.465). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation stratifying for: i) history of multiple suicide attempts; ii) history of previous psychiatric treatment; iii) use of alcohol during the index suicide attempt Follow‐up period: 6 months N lost to follow‐up: 8/133 (6.0%) for repetition of SH | |
| Participants | Inclusion criteria: i) admitted to an emergency department or clinical department following an episode of SH Exclusion criteria: i) less than 12 years old; ii) diagnosed with any major psychiatric illness, including: schizophrenia, other psychoses, bipolar disorder, major depression, psychotic depression, mental retardation, and severe dementia; iii) unable to communicate in Danish without an interpreter Numbers: Of the 133 participants, 69 were allocated to the experimental arm and 64 to the control arm. Profile: 71.4% (n = 95) were female, 38.3% (n = 51) were multiple attempters Source of participants: patients admitted to an emergency or clinical department following an episode of SH. Location: Amager, Denmark | |
| Interventions | Experimental: assertive outreach delivered according to the Baerum model involving assertive outreach via home visits, telephone calls, email messages, and text messages, solution‐focused problem‐solving therapy, adherence therapy, and treatment continuity as participants were contacted by the same psychiatric nurse (as far as practical) throughout the course of treatment (Dieserud 2000). Control: TAU involving encouraging participants to contact their GP who could, where required, refer the participant on to further psychiatric or psychological treatment. Therapist: 1 consultant‐level psychiatrist and 2 psychiatric nurses Type of therapy offered: assertive outreach and compliance enhancement Length of treatment: maximum period of 6 months | |
| Outcomes | Included: i) repetition of SH according to hospital records; ii) suicide according to coroner's records Excluded: none | |
| Notes | Sources of funding: "The trial has been funded by a grant from the Danish Ministry of Social Affairs, the Lundbeck Foundation and the Health Insurance Foundation" (p. 297). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "We applied a stratified randomization procedure . . . this stratified randomization procedure. . . created eight categories and randomization was performed for each independently" (p. 293). Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Low risk | Quote: "Randomisation was performed by an independent office" (p. 293). |
| Blinding (performance bias and detection bias) | High risk | Quote: "The patient. . . knew who was a case and who was a control" (p. 293). |
| Blinding (performance bias and detection bias) | High risk | Quote: "[I]ntervention staff knew who was a case and who was a control" (p. 293). |
| Blinding (performance bias and detection bias) | Low risk | Quote: " [I]ndependent assessors (three psychiatrists) who reviewed all incidents did not have this information" on who had been allocated to the experimental or control arms (p. 294). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Outcomes were measured by an intent‐to‐treat design in which all patients were followed until the end of the trial, irrespective of whether the patient was still receiving or complying with the assigned treatment" (p. 294). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using web‐based randomisation software Follow‐up period: 12 months N lost to follow‐up: 0/66 (0%) by the 12‐month follow‐up period | |
| Participants | Inclusion criteria: i) aged 18 or older; ii) resident in Manchester, UK; iii) admitted to emergency departments following an episode of SH Exclusion criteria: i) required admission to a psychiatric unit; ii) not in possession of a telephone; iii) required admission to a general hospital for a period of greater than 7 days; iv) lived outside of the catchment area; v) experienced deterioration in psychosis symptoms; vi) denied having engaged in SH; vii) declined to participate Numbers: Of the 66 participants, 33 were allocated to the intervention arm and 33 to the control arm. Profile: no details are provided, although the authors note "[i]ntervention and usual treatment groups were similar in terms of age, gender" (p. 73). Source of participants: admissions to emergency departments following an episode of SH Location: Manchester, UK | |
| Interventions | Experimental: outreach involving mailing of an information leaflet listing both local and national sources of support, 2 semi‐structured telephone calls, and a series of letters mailed at 1, 2, 4, 6, 8, and 12 months designed to facilitate referral to appropriate specialist treatment as required Control: TAU involving referral to mental health services, social services, or voluntary‐sector services as required Therapist: clinical researchers. No other details on qualifications or experience were provided. Type of therapy offered: outreach through telephone contact and the mailing of frequent letters encouraging participants to make contact with the service Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide Excluded: i) number of emergency department attendances; ii) number of days on a medical inpatient ward; iii) number of face‐to‐face contacts with mental health services; iv) number of admissions to psychiatric inpatient services | |
| Notes | Source of funding: "commissioned by the National Institute for Health Research (NIHR) under its Program Grants for Applied Research scheme (RP‐PG‐0606‐1247)" (p. 74). Declaration of author interest: "N.K. chaired the Naitonal Institute for Health and Clinical Excellence (NICE) guideline development group and evidence for the longer‐term management of self‐harm. N.K., D.G., K.H. are members of the National Suicide Prevention Strategy Advisory Group" (p. 73). | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Randomisation was conducted via a remote Internet‐based service (www.sealedenvelope.com)" (p. 73). Comment: Use of computer‐based randomisation software is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "All outcome data were collected by researchers masked to allocation status" (p. 73). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Primary analysis was on an intention‐to‐treat basis" (p. 73). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using web‐based randomisation software using minimisation to ensure balance between the treatment and control groups with respect to site, sex, age, and history of episodes of SH prior to the index episode Follow‐up period: 18 months to 5 years N lost to follow‐up: 0/914 (0%) by the 18‐month follow‐up period | |
| Participants | Inclusion criteria: i) aged 20 years or older; ii) admitted to the emergency department at 1 of 17 hospitals following a suicide attempt; iii) have at least 2 prior suicide attempts rated as having definite suicidal intent as determined by scores on the Suicide Intent Scale; iv) diagnosed with any axis I psychiatric disorder according to DSM‐IV‐TR criteria; v) able to understand the trial procedure; vi) provide informed consent; vii) attend a face‐to‐face interview; viii) attend a psychoeducation session during their hospital admission Exclusion criteria: i) diagnosed with any psychiatric disorder which did not meet DSM‐IV‐TR criteria Numbers: Of the 914 participants, 460 were allocated to the intervention arm and 454 to the control arm. Profile: 56.2% (n = 514) were females, 49.2% (n = 450) had multiple episodes of attempted suicide Source of participants: admissions to emergency departments following a suicide attempt Location: various locations around Japan | |
| Interventions | Experimental: assertive outreach and case management involving contact with patients at week 1 and 1, 2, 3, 6, 12, and 18 months after the index suicide attempt with a view to collecting information about the participant's treatment status and any problems that could interfere with treatment adherence, providing encouragement to remain adherent with treatment, coordination and referral to appointments with psychiatrists and any other primary care physicians, outreach for those who had dropped out of treatment, referral to social services and other support organisations as needed, psycho‐education, and access to a dedicated website designed to provide participants with information and resources Control: enhanced usual care. No further details on treatment content provided Therapist: mixture of psychiatrists, nurses, social workers, and clinical psychologists Type of therapy offered: assertive outreach Length of treatment: 18 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide Excluded: none | |
| Notes | Source of funding: "This study was funded by the Ministry of Health, Labour, and Welfare of Japan" (p. 200) Declaration of author interest: no conflicts of interest reported | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Participants were randomly assigned (1:1) by and Internet‐based system . . . to either the intervention group (assertive case management) or the control group (enhanced usual care). Assignment was by the minimisation method, with four factors: participating hospital, sex, age. . . and history of previous suicide attempts before the current episode. We regarded these as factors that could affect the study outcomes." (p. 194) Comment: Use of computer‐based randomisation software is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "Participants were randomly assigned. . . by an Internet‐based system operated by a central, independent data centre" (p. 194) Comment: use of offsite randomisation would have ensured that allocation was concealed. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Outcome assessors were masked to group assignment, but patients. . . were not" (p. 194). |
| Blinding (performance bias and detection bias) | High risk | Quote: "Outcome assessors were masked to group assignment, but. . . case managers who provided the interventions were not" (p. 194). |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Outcome assessors were masked to group assignment. . . The assessors did not know the participants' assigned groups, the status of implementation of the intervention or information about events obtained by other on‐site staff" (p. 194). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Analyses were done in accordance with the intention‐to‐treat principle" (p. 196) |
| Selective reporting (reporting bias) | High risk | Comment: outcomes determined ad hoc. In addition, data on some protocol‐specified outcomes (e.g., number of repeat SH episodes, hopelessness) are yet to be published. |
| Other bias | Unclear risk | Comment: sample was biased towards more compliant patients who were willing and able to attend a psycho‐education session seminar at the commencement of treatment and were able to attend hospital regularly for face‐to‐face interviews and case management sessions. Additionally, those individuals who had engaged in non‐suicidal SH were excluded from participation. |
| Study characteristics | ||
| Methods | Allocation: random assignment Follow‐up period: 24 months N lost to follow‐up: 0/24 (0%) for repetition data | |
| Participants | Inclusion criteria: i) at least 1 previous suicide attempt Exclusion criteria: i) diagnosed with psychosis; ii) addicted to drugs and alcohol; ii) diagnosed with organic brain syndrome. Numbers: Of the 24 participants, 12 were assigned to the experimental arm and 12 to the control arm. Profile: 16 (67%) were female, 24 (100%) were multiple repeaters, 24 (100%) were diagnosed with depressive neurosis, most met criteria for personality disorder Source of participants: patients referred by psychiatric emergency services or hospital A&E departments following an episode of SH. Location: Los Angeles, CA, USA | |
| Interventions | Experimental: inpatient treatment involving behaviour therapy. Treatment consisted of social skills training, anxiety management, and family therapy. A therapeutic milieu with a token economy was also established. Aftercare at a community mental health centre or with a private therapist was also used as required. Control: inpatient treatment involving insight oriented therapy. Treatment consisted of individual therapy, group therapy and psychodrama, and family therapy. A therapeutic milieu with a token economy was also established. Aftercare at a community mental health centre or with a private therapist was also used as required. Therapist: 1 psychologist assisted by 2 bachelor level technicians Type of therapy offered: behavioural therapy Length of treatment: 10 days | |
| Outcomes | Included: i) repetition of SH according to self report; ii) suicidal ideation; iii) depression Excluded: i) reinforcement; ii) assertiveness; iii) fear | |
| Notes | Source of funding: "The project was made possible by grant MH 22804 from the Clinical Research Branch of the National Institute of Mental Helath to Michael Serber, MD, and R.P.L., the co‐principal investigators." (p. 1130). Declaration of author interests: no details on author interests provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Patients were randomly assigned" (p. 1127). Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: No details on allocation concealment were provided. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: No information on participant blinding was provided. However, both treatments were so similar that it is possible participants were unaware of which treatment they were receiving. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on outcome assessor blinding provided |
| Incomplete outcome data (attrition bias) | High risk | Comment: 4 participants dropped out during the early stages of the trial (2 in each arm) and were not included in any subsequent analyses, suggesting researchers undertook per protocol analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomised allocation via computer programme Follow‐up period: 24 months N lost to follow‐up: 24/63 (38.1%) participants were deliberately not included in the 24‐month follow‐up. | |
| Participants | Inclusion criteria: i) female; ii) diagnosed with borderline personality disorder; iii) at least 2 suicide attempts in the last 5 years, with at least 1 in the previous 8 weeks; iv) aged 18‐45 years; v) agree to trial conditions Exclusion criteria: Numbers: Of the 63 participants, 32 were allocated to the experimental arm and 31 to the control arm. Profile: 63 (100%) were female, 63 (100%) were multiple repeaters with multiple episodes of SH each and who were at high risk of further episodes of SH, 63 (100%) were diagnosed with borderline personality disorder Source of participants: clinically referred patients who had at least 1 episode of SH in the last 8 weeks Location: Seattle, WA, USA | |
| Interventions | Experimental: dialectical behaviour therapy involving cognitive behavioural treatment developed specifically for the treatment of for suicidal patients with borderline personality disorder (see Linehan 1993a), which targets increasing behavioural capabilities and motivation for treatment whilst also reinforcing functional behaviour. The manualised treatment consisted of 1 h per week of individual psychotherapy, 2.5 h per week of group skills training, telephone consultation as required (within each therapists' limitations), and weekly therapist team meetings. Control: TAU involving referral to alternative therapy Therapist: 5 psychologists, 1 clinical psychology graduate, and 1 psychiatrist Type of therapy offered: dialectical behaviour therapy Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH according to self report; ii) suicide; iii) compliance; iv) depression; v) suicidal ideation; vi) hopelessness Excluded: i) psychiatric admissions; ii) reasons for living | |
| Notes | Sources of funding: "This research was supported by grant MH34486 from the National Institute of Mental Health, Bethesda, Md (Dr Linehan). Declaration of author interests: Although no details on author interests were provided, Dr. Linehan was developed dialectical behaviour therapy. Other: Half (50%) of the self reported episodes of SH were checked against medical records, therapist records, and observer/nurse/physician ratings. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "randomized" (p. 1060; 1991 article). Comment: Correspondence with authors clarified that they used a computer programme to generate the random sequence. Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correpondence with authors clarified that allocation had been concealed. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Every effort was made to keep the assessors blind about treatment condition" (p. 1061). |
| Incomplete outcome data (attrition bias) | High risk | Comment: subsequent analyses appear to be based on those participants with available information at each follow‐up period, suggesting investigators undertook per protocol analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computerised adaptive minimisation procedure whereby participants were matched using 5 primary prognostic variables: i) number of lifetime suicide attempts or non‐suicidal self injuries combined; ii) number of psychiatric hospitalisations; iii) history of only suicide attempts, only non‐suicidal self‐injury, or both; iv) age; v) Beck Depression Inventory score > 30 or a Global Assessment of Functioning score < 45 for any comorbid condition Follow‐up period: 24 months N lost to follow‐up: 0/101 (0%) for repetition data | |
| Participants | Inclusion criteria: i) 18‐45 years; ii) female; iii) met criteria for borderline personality disorder; iv) at least 2 suicide attempts or episodes of SH in the past 5 years, with at least 1 in the past 8 weeks Exclusion criteria: i) lifetime diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, psychotic disorder not otherwise specified, or mental retardation; ii) seizure disorder requiring medication; iii) mandate to treatment; iv) requiring primary treatment for another debilitating condition Numbers: Of the 101 participants 52 were allocated to the experimental arm and 49 to the control arm. Profile: 101 (100%) were female, 97 (96%) had a lifetime diagnosis of a depressive disorder, 73 (72.3%) were diagnosed with major depression, and 30 (29.7%) had substance abuse. Source of participants: clinical referrals and individuals attending inpatient units, emergency rooms and outpatient clinics Setting: Seattle, WA, USA | |
| Interventions | Experimental: dialectical behavior therapy involving cognitive behavioural treatment developed specifically for the treatment of for suicidal patients with borderline personality disorder (see Linehan 1993a), which targets increasing behavioural capabilities and motivation for treatment whilst also reinforcing functional behaviour. The manualised treatment consisted of 1 h weekly individual psychotherapy, 2.5 h weekly group skills training, telephone consultation as required (within each therapists' limitations), and weekly therapist team meetings. Control: community treatment by experts specifically designed for the trial to control for factors previously uncontrolled in DBT trials. Whilst similar to TAU, as therapists were free to decide on type and dose of therapy they believed was most suited to the patient (minimum of 1 scheduled individual session per week), the characteristics of therapists were controlled via selection of therapists and supervisory arrangements. Therapists: specially trained to provide either experimental or control therapy Type of therapy offered: dialectical behaviour therapy Length of treatment: 1 year | |
| Outcomes | Included: i) repetition of SH according to the Suicide Attempt Self‐Injury Interview; ii) suicide; iii) suicidal ideation; iv) depression; v) compliance Excluded: i) severity of SH episode; ii) importance of reasons for living; iii) use of additional service (e.g., re‐presenting to A&E) | |
| Notes | Sources of funding: "This study was supported by grants MH34486 and MH01593 from the National Institute of Mental Health" (p. 765). Declaration of author interests: although no details on author interests were provided, Dr Linehan developed dialectical behaviour therapy. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Computerized adaptive minimization randomization procedure" (p. 758) Comment: Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: No details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Quote: "Initial assessments were done before informing subjects of treatment assignment" (p. 758). Comment: suggests participants were subsequently informed of treatment allocation |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Assessments were conducted by blinded independent clinical assessors" (p. 758). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "[W]e examined the effects of differential missing data and treatment dropout on each of our major outcome variables and found no evidence that the findings were biased by these differences" (p. 760). Comment: 111 participants were randomised, 10 were pilot cases (not analysed), 20 were lost to follow‐up, and 21 discontinued interventions. 101 were analysed overall. |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using an unknown method Follow‐up period: as this was a cross‐over trial, only data from the first follow‐up period at 6 months was extracted N lost to follow‐up: 0/68 (0%) for the 6‐month follow‐up period | |
| Participants | Inclusion criteria: i) aged 15‐74 years; ii) admitted to hospital following an episode of SH; iii) episode of SH was associated with significant suicidal intent as reported either at the intake interview or according to scores on Beck's Scale for Suicidal Ideation; iv) considered likely to be discharged from hospital within 2 days or able to be re‐approached if admitted for longer than 2 days; v) able to provide informed consent Exclusion criteria: i) currently receiving ongoing psychiatric treatment; ii) diagnosed with psychosis; iii) diagnosed with dementia Numbers: Of the 68 participants, 34 were allocated to the intervention arm and 34 to the control arm Profile: 50.0% (n = 34) were female Source of participants: patients admitted to hospital following an episode of SH Location: Colombo, Sri Lanka | |
| Interventions | Experimental: brief mobile treatment involving an assessment of mental health, meditation, problem‐solving therapy, interventions to increase social support, interventions to address alcohol or other substance misuse problems, a series of 10 telephone calls to reaffirm techniques learnt during treatment, the ability to access telephone messages to reaffirm techniques learnt during treatment, and a series of up to 26 text messages to encourage the participant to practice meditation techniques, problem‐solving skills, to seek social support, to avoid alcohol and other drugs, and to use the telephone helpline to get individual support in times of crisis Control: wait list Therapist: no details on qualifications or experience provided Type of therapy offered: brief problem‐solving treatment via mobile telephone Length of treatment: up to 26 weeks | |
| Outcomes | Included: i) repetition of SH; ii) suicide reattempts; iii) suicide; iv) suicidal ideation; v) depression Excluded: i) medical outcomes; ii) alcohol use; iii) drug use; iv) substance use severity | |
| Notes | Sources of funding: "We are grateful for funding from the Improving Relevance and Quality of Undergraduate Education (IRQUE) project of the University of Jeyewardenepura, Sri Lanka" (p. 155). Declaration of author interests: no details on author interests provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "The participants were randomly allocated" (p. 152). Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The assessor was blind to the treatment" (p. 152). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Intention to treat analyses. . . " (p. 152). |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on repetition of SH, suicide reattempts, and suicide from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computer‐generated sequence of numbers stratified by: i) sex; ii) repeater status; iii) site Follow‐up period: 6 and 12 months N lost to follow‐up: 107/433 (24.7%) by the 6‐month follow‐up period | |
| Participants | Inclusion criteria: i) aged 18‐64 years; ii) engaged in SH in the previous 3 days Exclusion criteria: i) diagnosed with psychosis, intellectual disability, sensory disability, or an organic cognitive impairment; ii) currently substance dependent according to scores on the Short Alcohol Dependent Data questionnaire; iii) imprisoned; iv) of no fixed abode Numbers: Of the 433 participants, 222 were allocated to the experimental arm and 211 to the control arm. Profile: 64.4% (n = 279) were female; 29.3% (n = 127) were multiple repeaters Source of participants: admissions to the emergency department following an episode of SH, or patients engaging in SH on acute psychiatric facilities even if this did not necessitate admission to the emergency department Location: Cork and Limerick, Republic of Ireland | |
| Interventions | Experimental: problem‐solving skills training involving manualised, group‐therapy sessions of interpersonal problem‐solving skills training Control: TAU involving assessment by mental health professional staff and by crisis staff, and referral to acute mental health or community‐based services, psychotherapy, and pharmacotherapy as necessary Therapist: 1 therapist and 1 co‐therapist who received training in the delivery of problem‐solving skills training Type of therapy offered: problem‐solving group therapy Length of treatment: 6 weeks | |
| Outcomes | Included: i) repetition of SH; ii) suicides; iii) suicidal ideation; iv) depression; v) hopelessness; vi) problem‐solving; vii) compliance Excluded: i) anxiety; ii) impulsiveness; iii) generalised self efficacy; iv) social life confiding/emotions skills; v) social life practical support skills; vi) social life negative skills | |
| Notes | Source of funding: "This work was supported by funding from the Health Service Executive (HSE) South, HSE Mid‐West, the HSE National Office for Suicide Prevention, the Health Research Board and Pobal‐Dormant Accounts Fund in Ireland" (p. 389). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "[P]articipants were randomly assigned to treatment conditions on the basis of a computer generated sequence of numbers" (p. 384). Comment: Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "Allocation was concealed using sealed opaque envelopes" |
| Blinding (performance bias and detection bias) | High risk | Comment: Correspondence with authors confirmed that participants were not blinded to treatment allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: Correspondence with authors confirmed that personnel were not blinded to treatment allocation. |
| Blinding (performance bias and detection bias) | Low risk | Quote: " [R]esearchers [were] masked to participant treatment allocation" (p. 384). |
| Incomplete outcome data (attrition bias) | High risk | Comment: subsequent analyses appear to be based on those participants with available information at each follow‐up period, suggesting per protocol analyses were undertaken. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using an open random number table Follow‐up period: 12 months N lost to follow‐up: 6/39 (15.4%) for repetition data | |
| Participants | Inclusion criteria: i) aged 15‐45 years Exclusion criteria: i) history of psychosis, mental retardation, or organic cognitive impairment; ii) requiring psychiatric treatment (day care or inpatient) Numbers: Of the 39 participants, 19 were allocated to the experimental arm and 20 to the control arm. Profile: 29 (74%) were female, 14 (35.6%) were multiple repeaters, 9 (23%) were diagnosed with dysthymia, 6 (15%) had dependent personality disorder, and 5 (13%) had alcohol abuse Source of participants: patients admitted to an A&E department following an episode of self‐poisoning Location: Cork, Republic of Ireland | |
| Interventions | Experimental: interpersonal problem‐solving skills training involving a manualised training regimen including instruction, active discussion, reflective listening, modelling, coping strategy, role playing, sentence completion, and prompting Control: brief problem‐solving therapy involving therapy focused on patients' current problems and prevention by helping patients gain insight into problems. No specific skills training Therapist: clinical psychologists and psychiatry registrars Type of therapy offered: interpersonal problem‐solving therapy Length of treatment: 5 weeks | |
| Outcomes | Included: i) repetition of SH according to hospital records and a GP questionnaire; ii) suicide; iii) compliance; iv) hopelessness; v) problem‐solving; vi) number of problems Excluded: i) self perception; ii) Optional Thinking Test; iii) awareness of consequences | |
| Notes | Sources of funding: no details on funding provided Declaration of author interests: Although no details on author interests were provided, Dr McLeavey was the developer of interpersonal problem‐solving skills training. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | High risk | Quote: " [P]articipants were assigned on a random basis to the two treatment groups using an open random number table" (p. 384). Comment: As the numbers table was open, it is possible there may have been bias in the generation of the random sequence. |
| Allocation concealment (selection bias) | High risk | Comment: As an open numbers table was used, it is possible there was bias in allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "An independent assessor, blind to the treatment conditions in which the patients had participated, administered both pretreatment and post‐treatment measures" (p. 385). |
| Incomplete outcome data (attrition bias) | High risk | Comment: Of the 50 randomised participants, 5 dropped out of treatment before completion and 6 were lost to follow‐up. Only the 39 participants that completed the trial were included in all subsequent analyses, however, suggesting that analyses were per protocol. |
| Selective reporting (reporting bias) | High risk | Comment: Numerical data on problem‐solving were not reported, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using pre‐generated block procedure Follow‐up period: outcomes after 1 year of active treatment are reported in this review N lost to follow‐up: unclear | |
| Participants | Inclusion criteria: i) met DSM‐IV criteria for borderline personality disorder;ii) 18‐60 years old; iii) at least 2 episodes of suicidal or non‐suicidal self injurious acts in the past 5 years with at least 1 in the 3 months proceeding enrolment Exclusion criteria: i) meeting DSM‐IV criteria for a psychotic disorder, bipolar I disorder, delirium, dementia, or mental retardation; ii) diagnosed with substance dependence in the preceding 30 days; iii) live outside of a 40‐mile radius of Toronto; iv) have a serious medical condition likely to require hospitalisation within the next year (e.g., cancer); v) have plans to leave the province of Ontario within the next 2 years Numbers: of the 180 participants, 90 were allocated to the experimental arm and 90 to the control arm. Profile: 155 (86.1%) were female, 180 (100%) were multiple repeaters, 180 (100%) met criteria for Borderline Personality Disorder, 135 (75%) had a current diagnosis of any anxiety disorder, 17 (9.4)% had a current diagnosis of substance abuse, 88 (48.9%) had a current diagnosis of major depression, 39 (21.7%) had a current diagnosis of panic disorder, and 71 (37.4%) had a current diagnosis of PTSD Source of participants: patients attending a specialised Centre for Addiction and Mental Health, hospital or both Location: Toronto, ON, Canada | |
| Interventions | Experimental: manualised dialectical behaviour therapy involving 1 h weekly sessions of individual therapy, 2 h weekly sessions of skills group training, and 2 h weekly of telephone‐based coaching aimed at providing psycho‐education about borderline personality disorder, improving personal relationships, and providing validation and empathy, within a 'here and now' focus on the prevention of self‐harm and suicidal behaviour. Additionally, therapists' attended weekly therapist team meetings. Control: general psychiatric management involving 1 h weekly sessions of individual therapy focused on improving medication management through the use of a structured drug algorithm. Participants also received psycho‐education about borderline personality disorder, improving personal relationships, and providing validation and empathy, within a 'here and now' focus. Additionally, therapists' attended weekly therapist team meetings. Therapists: 7 doctoral‐level clinicians and 1 board‐certified psychiatrist Type of therapy offered: dialectical behaviour therapy Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iii) depression; iv) number completing full 1 year course of treatment Excluded: i) repetition of NSSI | |
| Notes | Sources of funding: "Supported by grant 200204MCT‐101123 from the Canadian Institutes for Health Research" (p. 1373). Declaration of author interests: "Dr. Links has received an unrestricted educational grant from Eli Lilly Canada Inc. All other authors report no competing interests" (p. 1373). Other: data on hospital admissions for self‐harm obtained from self report following clinician interview | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Eligible participants were randomly assigned to treatment arms using a pre‐generated block randomization scheme developed and held by the statistician" (p. 1366) Comment: Use of a pre‐generated block randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "[T]he statistician, who prepared 45 sealed envelopes, each containing the group allocations in random order for four participants" (p. 1366) Comment: although no details on whether the envelopes were opaque is not provided, it is likely they were thereby ensuring adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: As this was a single blind trial, participants were aware of the treatment group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Quote: "The study coordinator… was not blind to treatment assignment" (p. 1366) Comment: As this was a single blind trial, all personnel, not just the trial coordinator, are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "Assessors . . . were. . . blind to treatment assignment" (p. 1366). Additionally, "Assessors were polled after the treatment phase to ascertain whether they could correctly guess participants' treatment assignment; they did not know treatment assignment for 86% of the cases, suggesting that blinding was largely maintained" (p. 1366). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All results were analysed using an intent‐to‐treat analysis (n = 180). We also conducted a per‐protocol analysis based on 'treated' participants, defined as those who were in treatment for at least 8 weeks from initial session to last session. This included a total of 167 patients (dialectical behavior therapy, n = 85; general psychiatric management, n = 82)" (p. 1370). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a supply of sealed envelopes, half of which contained an emergency green card Follow‐up period: 12 months N lost to follow‐up: 0/212 (0%) for repetition data | |
| Participants | Inclusion criteria: i) no previous episode of SH; ii) resident within healthcare trust catchment area Exclusion criteria: none stated Numbers: of the 212 participants, 101 were allocated to the experimental arm and 111 to the control arm Profile: 25% (n = 53) were diagnosed with any depressive disorder, 100% (n = 212) were non‐repeaters Source of participants: patients admitted to hospital following first episode of SH Location: Bristol, UK | |
| Interventions | Experimental: emergency green card in addition to TAU. The green card outlined that a doctor was available by telephone and how to contact them. Control: TAU involving referral to the primary healthcare team, and psychiatric or inpatient admissions if required Therapist: telephone contact, face‐to‐face interviews, or both conducted by a doctor on‐call Type of therapy offered: emergency green card Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH according to hospital, psychiatric, and GP records Excluded: i) use of the green card; ii) admission to psychiatric hospital; iii) use of psychiatric services | |
| Notes | Source of funding: no details on funding were provided Declaration of author interests: no details on author interests provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Allocation to experimental or control group was carried out by random selection from a supply of closed envelopes, half of which contained the green card" (p. 111) Comment: Randomisation using sealed envelopes is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "closed envelopes" (p. 111) Comment: Although authors provide no details on whether the envelopes were opaque, it is likely they were, thereby ensuring adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Quote: "[Patients] receive[ed] the green card" (p. 111) Comment: suggests participants would have known to which treatment arm they had been allocated |
| Blinding (performance bias and detection bias) | Unclear risk | Quote: "GPs were also sent copies of the green card" (p. 111) Comment: It is unclear if they knew which of their patients received the intervention. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on outcome assessor blinding provided |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "Data concerning outcome were obtained for all patients included in the study" (p. 111). Comment: Subsequent analyses include all those randomised to the experimental and control groups, suggesting intention‐to‐treat analyses were undertaken. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using computer‐based software and stratified by: i) history of suicide attempts; ii) history of psychiatric treatment or hospitalisation; iii) alcohol consumption at the time of the index suicide attempt Follow‐up period: 12 months N lost to follow‐up: 0/243 for primary outcomes (suicide reattempts, suicide). 74/243 (30.4%) for secondary outcomes (depression, compliance) | |
| Participants | Inclusion criteria: i) 12 years or older; ii) admitted to acute emergency units, intensive care units, paediatric units, or psychiatric emergency room units following a suicide attempt Exclusion criteria: i) living in an institution; ii) admitted to a psychiatric unit for more than 14 days; iii) diagnosed with a schizophrenia‐spectrum disorder; iv) diagnosed with severe depression, bipolar disorder, or dementia; v) currently receiving outreach services from social service agencies Numbers: Of the 243 participants, 123 were allocated to the intervention arm and 120 to the control arm. Profile: 75.7% (n = 184) were female; 53.5% (n = 130) were multiple repeaters Source of participants: patients admitted to acute emergency units, intensive care units, paediatric units, or psychiatric emergency room units following a suicide attempt Location: Copenhagen, Denmark | |
| Interventions | Experimental: assertive intervention involving case management, crisis intervention as required, problem‐solving therapy, and assertive outreach based on motivational support to encourage patients to attend treatment sessions, assist patients to attend these sessions, and to improve adherence to after‐treatment in addition to TAU Control: TAU involving referral to a range of different treatments depending on diagnosis, clinical, and social needs. Treatment included a psychiatric assessment and may also incorporate substance abuse treatment, psychological therapy, and GP referral as required. Pharmacological treatment was also provided where necessary. Therapist: psychiatric nurses who had received training in suicidology Type of therapy offered: assertive outreach Length of treatment: 6 months | |
| Outcomes | Included: i) suicide reattempts; ii) suicide; iii) depression; iv) compliance Excluded: none | |
| Notes | Sources of funding: "This study received funding from the Ministry of Health and Internal Affairs, Denmark, the National Board of Social Services, and independent subdivision of The Ministry of Social Affairs and Integration, TrygFoden, and Aase og Ejnar Danielsens Foundation" (p. 6). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Computer randomisation was done. . . stratified by whether the patient had previously attempted suicide (first attempt v previous attempt), previous psychiatric contacts or hospitalisations (none v previous contacts), and alcohol consumption at the time of suicide attempt (none v alcohol consumption . . . The randomisation procedure ensured adequate sequence generation. . . " (p. 3). Comment: Use of a computer‐based randomisation procedure is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "Computer randomisation was done by an independent research assistant . . . The randomisation procedure ensured adequate. . . allocation concealment" (p. 3) |
| Blinding (performance bias and detection bias) | High risk | Quote: "[P]articipants were immediately informed of the outcome [i.e., allocation]" (p. 3). Comment: suggests participants were not blind as to treatment allocation |
| Blinding (performance bias and detection bias) | High risk | Quote: "Owing to the nature of the study design, the intervention staff were not blinded" (p. 3). |
| Blinding (performance bias and detection bias) | Unclear risk | Quote: "An external medical evaluation committee conducted a blinded outcome assessment using medical records" (p. 3). However, authors later state that: "The researcher conducting the analyses on self‐reported outcomes was. . . not blinded." (p. 3). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All participants were included in the analysis regardless of subsequent adherence to treatment, according to the intention to treat principle" (p. 3). |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: random allocation Follow‐up period: 3 weeks N lost to follow‐up: no details provided | |
| Participants | Inclusion criteria: i) admitted to a psychiatric ward following a suicide attempt Exclusion criteria: ii) diagnosed with psychosis; ii) diagnosed with substance abuse Numbers: Of the 15 participants, 10 were allocated to the experimental arms (5 to the cognitive restructuring arm and 5 to the problem‐solving arm), and 5 were allocated to the control arm. Profile: no details provided Source of participants: patients admitted to a psychiatric ward following a suicide attempt Location: Charleston, SC, USA | |
| Interventions | Experimental: 10 one‐hour sessions of cognitive restructuring with a focus on suicidal ideation or problem‐solving Control: non‐directive therapy involving open discussions about suicidal behaviour, problems, and daily life Therapist: The same therapist conducted therapy sessions for all 3 arms. Type of therapy offered: i) cognitive therapy; ii) problem‐solving therapy Length of treatment: 3 weeks | |
| Outcomes | Included: i) repetition of SH according to an unknown source; ii) suicidal ideation (measured in 2 ways); iii) hopelessness; iv) problem‐solving; v) problem‐solving skills Excluded: i) flexibility of thinking | |
| Notes | Sources of funding: no details provided Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Subjects were randomly assigned" (p. 282). Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: As the same therapist provided therapy for all 3 arms, personnel would have known which participant was receiving which treatment |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on outcome assessor blinding provided |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: no details provided on whether intention‐to‐treat analyses were conducted |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computer‐generated algorithm Follow‐up period: 12 months N lost to follow‐up: 10/80 (12.5%) by the 12‐month follow‐up period | |
| Participants | Inclusion criteria: i) aged 16 years or older; ii) engaged in SH on 5 or more days in the year prior to randomisation; iii) diagnosed with at least 1 personality disorder Exclusion criteria: i) diagnosed with a severe learning disability that would interfere with the ability to benefit from DBT; ii) unable to read or write in English Numbers: Of the 80 participants, 40 were allocated to the intervention arm and 40 to the control arm. Profile: 87.5% (n = 70) were female Source of participants: referrals to a specialist DBT service Location: London, UK | |
| Interventions | Experimental: dialectical behaviour therapy delivered according to Linehan (i.e., Linehan 1993b) involving both individual and group‐based cognitive behavioural therapy, mindfulness, validation, supportive therapeutic techniques, and skills training. Out‐of‐hours telephone skills training was also available as required. Control: TAU involving referral back to the referee agency where the participant was encouraged to engage with any treatment other than DBT, including psychotherapy, referral to psychiatrists, mental health teams, counsellors, GPs, or other user‐run support services Therapist: no details on qualifications or clinical experience reported Type of therapy offered: dialectical behaviour therapy Length of treatment: 12 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iii) compliance. Excluded: i) days with SH; ii) borderline personality disorder symptom severity; iii) psychiatric disorder symptom severity; iv) quality of life | |
| Notes | Sources of funding: "This paper. . . [was] funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit Programme (grant reference No. PB‐PG‐0906‐10540). All authors were funded by this grant with the exception of K.B. whose contribution was funded by the NIHR Doctoral Research Fellowship Scheme" (p. 364). | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Randomisation was computer generated with a 1:1 allocation. . . using 6 blocks of 12 randomly permuted treatment allocation sequences, with a final block of 8." (p. 358). Comment: Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "[T]he data analyst remained masked throughout the study period" (p. 358). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "[M]issing covariate values were . . . [estimated using] maximum likelihood estimation [to] ensure . . . unbiased parameter estimates. We. . . [also] conducted a sensitivity analysis with last observation carried forward." (p. 358). |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to obtain data on repetition of SH and suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: predetermined random allocation using sampling without replacement and sealed envelopes Follow‐up period: 12 months N lost to follow‐up: 0/20 (0%) for repetition data | |
| Participants | Inclusion criteria: i) aged 16‐65 years; ii) of fixed abode and living within Health Authority boundary; iii) antidepressants were taken as part of the self‐poisoning episode; iv) a history of 2 or more previous suicide attempts; v) Buglass and Horton Risk of Repetition Scale score of at least 4. Participants had to fulfil at least 2 criteria to be included. Exclusion criteria: i) not requiring immediate psychiatric treatment; ii) diagnosed with psychosis; iii) diagnosed with a serious organic illness. Numbers: of the 20 participants, 12 were allocated to the experimental arm and 8 to the control arm. Profile: 10 (50%) were female, 20 (100%) were multiple repeaters with a high risk of further repetition Source of participants: patients referred by the duty psychiatrist following an episode of self‐poisoning using antidepressant and assessed in an A&E department Setting: Leeds, UK | |
| Interventions | Experimental: 5 one‐hour sessions of domiciliary (home‐based) cognitive‐behavioural problem‐solving treatment Control: TAU Therapist: community psychiatric nurse Type of therapy offered: problem‐solving therapy Length of treatment: 1 month | |
| Outcomes | Included: i) repetition of SH according to hospital records; ii) depression; iii) hopelessness; iv) suicide; v) suicidal ideation (measured in 2 ways); vi) severity of 3 main problems; vii) problem‐solving Excluded: i) mood | |
| Notes | Sources of funding: no details provided Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Predetermined random allocation" (p. 872) Comment: Correspondence with authors clarified that the method used was "sampling without replacement using envelopes". |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors clarified that sealed envelopes were used to conceal allocation. Use of sealed envelopes would ensure adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: Although it is possible that outcome assessors could have rated data on repetition of self‐poisoning from hospital records blind, other assessments were gathered by the same psychiatric nurse who delivered the intervention. |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "There were no treatment drop outs" (p. 872) |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation by computer and random number generator Follow‐up period: 3 months, 6 months and 9 months N lost to follow‐up: 8/90 (21%) for repetition of SH data | |
| Participants | Inclusion criteria: i) recently engaged in self‐harm; ii) aged 15‐35; iii) Dutch‐speaking; iv) live in the Leiden region Exclusion criteria: i) diagnosed with a psychiatric disorder requiring intensive inpatient treatment; ii) diagnosed with a cognitive impairment Numbers: Of the 90 participants, 48 were allocated to the experimental arm and 42 to the control arm. Profile: Of the 82 participants who received the intervention, 77 (93.9%) were female. Source of participants: patients presenting to hospital/mental health centre following an episode of self‐harm Setting: Leiden, the Netherlands | |
| Interventions | Experimental: 12 sessions of CBT in addition to TAU Control: TAU involving psychotropic medication, psychotherapy, or hospitalisation as required Therapist: experienced CBT practitioners Type of therapy offered: cognitive‐behavioural therapy Length of treatment: 5.5 months | |
| Outcomes | Included: i) repetition of SH from self report; ii) suicide; iii) depression; iv) compliance; iv) problem‐solving Excluded: i) anxiety; ii) self esteem; iii) suicidal cognition; iv) use of psychological and psychiatric services | |
| Notes | Sources of funding: "Support for the study was provided by The Netherlands Organisation for Health Research and Development (AonMw) (contract grant number: 2100.0068)" (p. 210). Other: Repetition data provided by participants was subjected to reliability analysis by comparing self reports to hospital records and information from treatment sessions. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Randomisation to treatment was accomplished using a computer program and a random‐number generator provided by an independent investigator" (p. 203) Comment: use of a random‐number generator is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Comment: Correspondence with authors clarified that computerised, central allocation had been used to conceal allocation. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Masking of follow up assessments was not possible because participants were asked about their use of healthcare services at each assessment" (p. 203). |
| Blinding (performance bias and detection bias) | High risk | Quote: "Masking of follow up assessments was not possible because participants were asked about their use of healthcare services at each assessment" (p. 203) Comment: As personnel were required to question participants about their use of healthcare services, this would suggest that personnel would have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | High risk | Comment: all measures were self reports. Participants were not blinded at follow‐up. |
| Incomplete outcome data (attrition bias) | Low risk | Comment: of the 90 participants randomised, 8 did not receive their allocated intervention and 9 were lost to follow‐up. Analyses are conducted both including and excluding these participants, suggesting a combination of per protocol and intention‐to‐treat analyses (using the LOCF method). |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using the method of drawing names from a hat Follow‐up period: 2 months N lost to follow‐up: unknown as no apparent attempt was made to follow‐up patients who did not complete treatment | |
| Participants | Inclusion criteria: i) suicide attempt with self reported suicide intent; ii) admitted to 1 of the 2 participating hospitals Exclusion criteria: i) diagnosed with an intellectual disability; ii) current diagnosis of mania, psychosis, or both; iii) under 18 years. Correspondence with authors further clarified that 1 participant was subsequently excluded after randomisation due to being a frequent repeater of SH, possibly due to borderline personality disorder. Numbers: Of the 32 participants, 11 were allocated to the CBT arm, 12 were allocated to the PST arm, and 9 were allocated to the control arm. Profile: 53.1% (n = 17) were female Source of participants: patients admitted to 1 of 2 participating hospitals following a suicide attempt Location: Brisbane (QLD), Australia | |
| Interventions | Experimental: 4 weekly individual sessions of cognitive‐behavioural therapy or 7 weekly individual sessions of problem‐solving therapy. Cognitive‐behavioural therapy was offered as a manualised treatment involving elements of both Beck's cognitive behaviour therapy and Ellis' theory of rational emotive therapy (Ellis 1986; Ellis 1996). Problem‐solving therapy was also manualised and was based on the 6‐step model of D'Zurilla 1971. Control: TAU involving treatment by the hospital acute care team Therapist: treatment was provided by "the researcher" (p. 542). No further details on qualifications, training, or experience provided Type of therapy offered: i) cognitive‐behavioural therapy; ii) problem‐solving therapy Length of treatment: 2 months | |
| Outcomes | Included: i) suicide reattempts; ii) suicides; iii) suicidal ideation; iv) hopelessness; v) problem‐solving; vi) compliance. Excluded: i) satisfaction with treatment | |
| Notes | Sources of funding: no details provided Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Comment: Correspondence with authors clarified that "[n]ames of treatment groups were drawn from a container and participants were allocated to a treatment group." |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment were provided |
| Blinding (performance bias and detection bias) | High risk | Comment: correspondence with authors clarified that the "treatment condition was offered to the client via a phone call", suggesting that participants would have known to which treatment arm they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: Correspondence with authors clarified that the therapist running the research was aware of which treatment condition the participant was being offered. |
| Blinding (performance bias and detection bias) | High risk | Comment: Correspondence with authors clarified that the "therapist collected outcome data via self‐report measures and chart audits." Neither participants nor personnel were blinded as to which treatment arm participants had been allocated. |
| Incomplete outcome data (attrition bias) | High risk | Comment: Correspondence with authors clarified that 10 participants dropped out of the TAU arm, 12 dropped out of the CBT arm, and 11 dropped out of the PST arm. It would appear that data were only collected on patients who completed treatment and that no intention‐to‐treat analyses were attempted. |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to obtain data on suicidal ideation, hopelessness, problem‐solving (for TAU arm), repetition of suicide attempts (for TAU and PST arms), and suicides (for TAU, CBT, and PST arms) following correspondence with authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a coin toss Follow‐up period: 4 and 6 months N lost to follow‐up: 3/16 (18.7%) for incidence of SH during the 6‐month follow‐up period. | |
| Participants | Inclusion criteria: i) aged 18‐65 years; ii) able to communicate effectively in Finnish, including reading and writing; iii) living within the hospital catchment area Exclusion criteria: none stated Numbers: Of the 16 participants, 9 were allocated to the experimental arm and 7 were allocated to the control arm. Profile: 100% (n = 16) were female Source of participants: admissions to an emergency department following a episode of SH Location: Jyväskylä, Finland | |
| Interventions | Experimental: acceptance commitment therapy and solution‐focused brief therapy involving meditation, identification of problems, strategies to solve these problems, reflection on alternative methods of problem‐solving, providing motivation to solve these problems, frustration tolerance exercises, and identity assimilation exercises. Control: Correspondence with authors clarified that TAU involved psychiatric outpatient treatment in the form of supportive sessions with a mental health nurse in addition to pharmacological treatment as required. Therapist: advanced level psychology students who received 36 h of training in acceptance and commitment therapy and solution‐focused brief therapy Type of therapy offered: brief psychological therapy Length of treatment: 4 weeks | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iii) depression Excluded: i) anxiety; ii) health‐related quality of life; iii) action and acceptance; iv) difficulties in emotion regulation | |
| Notes | Source of funding: no details provided Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Comment: Correspondence with authors clarified that randomisation was with a simple coin toss. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Quote: "The assessor was not blind to conditions; however, all outcome measures were self‐reported, and there was limited interaction between participants and the assessor." (p. 97). |
| Incomplete outcome data (attrition bias) | High risk | Comment: participants who did not receive treatment appear to have been excluded from all subsequent analyses, suggesting that investigators undertook per protocol analyses. |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on repetition of SH and suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using an unknown method Follow‐up period: 12 months N lost to follow‐up: 11/141 (5.7%) for repetition of SH data | |
| Participants | Inclusion criteria: i) admitted to the toxicology department of a hospital following a suicide attempt by acute intoxication Exclusion criteria: i) diagnosed with psychosis Numbers: Of the 141 participants, 68 were allocated to the experimental arm and 73 to the control arm. Profile: 63.1% (n = 89) were female, 48.2% (n = 68) were multiple repeaters, 100% (n = 141) had engaged in self‐poisoning Source of participants: patients hospitalised following a suicide attempt Location: Munich, Germany | |
| Interventions | Experimental: short crisis intervention during hospital stay followed by a fixed outpatient appointment with the same therapist. Treatment involved a motivational interview, as well as a letter and assessment of motivation towards therapy. Control: short crisis intervention during hospital stay followed by a fixed outpatient appointment with a different therapist. Treatment involved a motivational interview, as well as a letter and assessment of motivation towards therapy. Therapist: 3 therapists trained in psychotherapy and 1 therapist trained in behaviour therapy Type of therapy offered: compliance enhancement plus therapy delivered by the same therapist as in hospital. Length of treatment: 3 months | |
| Outcomes | Included: i) repetition of SH according to self report; ii) suicide; iii) compliance; iv) depression Excluded: none | |
| Notes | Sources of funding: no details provided Declaration of author interests: no details provided Other: in the first phase of this trial, the efficacy of standard care was assessed in terms of compliance. 85 participants were not randomly assigned to this group but were instead "referred routinely" (p. 53). | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Patients were randomly offered [intervention or control treatment]" (p.54) Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | High risk | Comment: no details on outcome assessor blinding provided. However, most outcome measures, with the exception of data on suicides, were self reported. Given the nature of this trial, participants could have known to which group they had been allocated. |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: 11 participants were lost to follow‐up. A greater number of participants in the control arm (n = 7) dropped out compared to number in the experimental arm (n = 4). No details on whether intention‐to‐treat analyses were conducted was provided. |
| Selective reporting (reporting bias) | Unclear risk | Comment: No reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | High risk | Quote: "There is some evidence that patients of the experimental group . . . had more risk factors for further suicidal behavior than did patients of the control group . . . despite randomization. In the experimental group there were more older patients . . . more men . . . more divorced persons . . . and more had been hospitalised in psychiatry in the past . . . Also, there were more parasuicides in the 12 months before index parasuicide. . . Most differences did not reach statistical significance; nevertheless, they can indicate some unequal distribution of risk factors between treatment groups" (p. 56). |
| Study characteristics | ||
| Methods | Allocation: randomisation using an unknown method Follow‐upperiod: 12 months N lost to follow‐up: 0/80 (0%) for repetition of SH data | |
| Participants | Inclusion criteria: i) able to understand German; ii) living within travelling distance of research centre; iii) previous episodes of SH Exclusion criteria: i) diagnosed with endogenous psychosis; ii) already in psychotherapeutic treatment; iii) already in inpatient psychiatric treatment; iv) overdose involved use of illicit drugs Numbers: Of the 80 participants, 40 were allocated to the experimental arm and 40 to the control arm. Profile: 100% (n = 80) were multiple repeaters Source of participants: patients who were hospitalised following an episode of deliberate self‐poisoning and who were referred to the liaison service of toxicological ward Location: Munich, Germany | |
| Interventions | Experimental: long‐term therapy involving 1 therapy session per month over a period of 12 months in addition to a brief crisis intervention delivered 3 days after admission. Control: short‐term therapy involving 12 weekly therapy sessions over a period of 3 months in addition to a brief crisis intervention delivered 3 days after admission. Therapist: 3 psychiatric attendants. Type of therapy offered: no further details on the content of therapy sessions provided Length of treatment: for the experimental arm, 12 months; for the control arm, 3 months | |
| Outcomes | Included: i) repetition of SH according to an unknown source; ii) compliance; iii) depression Excluded: i) complaints; ii) psychopathology | |
| Notes | Sources of funding: "Supported by a grant from the FRG Ministry for Research and Technology" (p. 419) Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Quote: "Randomly assigned" (p. 419) Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment were provided. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on outcome assessor blinding provided |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: Of the 80 participants, data on 50‐67% were available at 3 months, and data on 97.5% were available at 12 months. Self and experts' ratings data from personal follow‐up were available for 85% of participants. No details provided on whether intention‐to‐treat analyses were conducted |
| Selective reporting (reporting bias) | High risk | Comment: numerical data on depression scores not reported, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomised using an unknown method Follow‐up period: 12 months N lost to follow‐up: 0/24 (0%) for repetition of SH at the 6‐ and 12‐month follow‐up assessments | |
| Participants | Inclusion criteria: i) diagnosed with borderline personality disorder according to both the Diagnostic Interview for Borderlines and the Personality Disorders Examination criteria ; ii) admitted to hospital following a suicide attempt; iii) able to provide written informed consent; iv) consent to randomised assignment Exclusion criteria: i) diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, organic mental disorder, mental retardation Numbers: Of the 24 participants, 12 were allocated to the intervention arm and 12 were allocated to the control arm. Profile: 79.2% (n = 19) were female, 95.8% (n = 23) met criteria for a comorbid Axis I disorder, including: dysthymia with a comorbid generalised anxiety disorder (n = 17), major depression (n = 3), and dysthymia (n = 3). 95.8% (n = 23) met criteria for a comorbid Axis II disorder, including: dependent personality disorder (n = 9), histrionic personality disorder (n = 6), narcissistic personality disorder (n = 6), schizotypal personality disorder (n = 3), antisocial personality disorder (n = 2), paranoid personality disorder (n = 2), and compulsive personality disorder (n = 1). 75.0% (n = 18) had alcohol misuse, 83.3% (n = 20) had substance misuse. Source of participants: patients admitted to hospital following a suicide attempt Location: Philadelphia, PA, USA | |
| Interventions | Experimental: dialectical behaviour therapy involving elements of Linehan's manualised DBT protocol (see Linehan 1993a) but modified to include: i) psychodynamic techniques to conceptualise patients' behavioural, emotional, and relationship schema. Additionally, no group skills training sessions were provided. Instead, skills training occurred during individual therapy. The 6 sessions intended to be used as group skills training sessions were instead used for interpersonal skills training focusing on the identification of significant persons in the participants' environment, including problems in relationships, with family, etc. Control: client‐centred therapy based on Carkhuff's model involving emphatic understanding of the patients' sense of aloneness and the provision of a supportive atmosphere to enable individuation (Carkhuff 1969; Carkhoff 1976). Carkhuff's manual provides directions for increasing the therapeutic relationship through emphatic and supportive elements. The primary focus of treatment was to provide support to enable participants to deal with everyday stress and prevent relapse. Participants also received 6 sessions of interpersonal skills training focusing on the identification of significant persons in the participants' environment, including problems in relationships, with family, etc. Treatment also included the creation and signing of a contract by the therapist and patient stipulating that the patient would not engage in SH or make a suicide attempt during the 12‐month treatment period. Therapist: 4 therapists with an average of 22 years' clinical experience in family systems, client‐centred, and psychodynamic treatment therapies. All therapists also received 12 sessions of training in dialectical behaviour therapy delivered over a 3‐month period prior to randomisation. Type of therapy offered: dialectical behavioural therapy Length of treatment: 12 months | |
| Outcomes | Included: i) suicide reattempts according to self report; ii) suicides; iii) suicidal ideation according to self report; iv) depression according to self report Excluded: i) impulsiveness; ii) anger; iii) anxiety; iv) psychiatric symptomatology; v) days in hospital | |
| Notes | Sources of funding: no details provided Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Participants [were] randomly assigned. . . " (p. 414). Comment: the authors further note that "To determine if the random assignment procedure worked, we examined the pretreatment values of the dependent variables for each . . . outcome. . . there were no significant differences between the groups" (pp. 416‐417), suggesting that the random sequence generation was unbiased. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "The independent assessor was unaware of the patients' treatment condition. . . " (p. 415). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All 24 patients participated in the 6 month and 12 month assessments and composed the intention‐to‐treat sample for the analyses" (p. 414). Comment: no additional details provided on the method used to perform intention‐to‐treat analyses |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: central independent telephone randomisation system using a computer allocation sequence composed of randomly permuted blocks of sizes 2, 4, and 6 in a non‐systematic sequence. Randomisation stratified by hospital and parasuicide risk Follow‐up period: 12 months N lost to follow‐up: 50/480 (10%) for repetition of SH data | |
| Participants | Inclusion criteria: i) aged 16‐65 years; ii) previous history of SH; iii) able to provide informed consent; iv) sufficient English to provide informed consent; v) live in the catchment area; vi) likely to be available for follow‐up Exclusion criteria: ii) have an ICD‐10 diagnosis within the organic, alcohol and drug dependence, schizophrenia or bipolar affective disorder group of codes; viii) psychiatric hospitalisation required. Numbers: Of the 480 participants, 239 were allocated to the experimental arm and 241 to the control arm. Profile: 67.9% (n = 326) were female, 42.1% (n = 202) were diagnosed with a personality disorder Source of participants: patients presenting to hospital following an episode of SH Location: Glasgow, Edinburgh, Nottingham, West London, and South London, UK | |
| Interventions | Experimental: manual‐assisted cognitive‐behavioural therapy involving an evaluation of the most recent suicide attempt, crisis skills problem‐solving therapy, cognitive techniques for emotional, and negative thinking management, and the development of relapse prevention strategies Control: TAU involving psychiatric assessment, outpatient care, occasional day‐patient care, referral to GP, or a combination of these Therapist: therapists from the existing services Type of therapy offered: cognitive‐behavioural therapy Length of treatment: 3 to 6 months | |
| Outcomes | Included: i) repetition of SH according to self report and verified by GP notes, hospital records, or both; ii) suicide; iii) depression Excluded: i) anxiety; ii) social functioning; iii) quality of life; iv) global functioning; v) future thinking | |
| Notes | Sources of funding: "The POPMACT study is funded by the Medical Research Council of the United Kingdom" (p. 67). Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "After initial research assessments, participants were randomised to either MACT or TAU using a central independent telephone randomising system so that patients could be allocated to treatment immediately. . . Stata software was used to generate allocation using randomly permuted blocks of sizes two, four and six in a non‐systematic sequence. Random allocation was stratified by participating hospital and parasuicide risk status (high versus low)" (p. 60) Comment: Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "After initial research assessments, participants were randomised to either MACT or TAU using a central independent telephone randomising system. . . " (p. 60) Comment: Use of central allocation means that allocation was probably concealed. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on outcome assessor blinding provided |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: of the 480 participants randomised, we could not obtain 12‐month data for 78 (16.2%) for the following reasons: i) could not be traced (n = 27); ii) refused follow‐up assessment (n = 19); iii) did not attend follow‐up assessment (n = 9); iv) died (n = 8); v) withdrew (n = 4); vi) other reasons (n = 11). No details provided on whether intention‐to‐treat analyses were conducted. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computer‐generated list of pseudo‐random numbers in opaque sealed envelopes Follow‐up period: 13 months N lost to follow‐up: 0/605 (0%) for suicide reattempts data | |
| Participants | Inclusion criteria: i) aged 18‐65 years; ii) hospitalised following a suicide attempt by drug overdose; iii) examined by a psychiatrist who agreed to patients' discharge; iv) able to provide name of GP; v) able to be be contacted by phone; vi) able to provide written consent Exclusion criteria: i) homeless; ii) addicted to illicit drugs Numbers: of the 605 participants, 293 were allocated to the experimental arm and 312 to the control arm. Profile: 72.9% (n = 441) were female, 9% (n = 54) had history of more than 4 suicide attempts in the past 3 years, 49% (n = 296) had experienced a stressful life event in past 6 months. Source of participants: patients presenting to hospital following a drug overdose Setting: Lille, France | |
| Interventions | Experimental: telephone contact involving a review of the emergency department recommended treatment in addition to TAU. Where participants found the the treatment recommended during their hospitalisation too difficult to follow, a new regimen was suggested. For those at high risk of suicide, an urgent appointment was made at the emergency department where the patient initially received treatment. No therapy other than support was provided. Control: TAU typically involving referral to the participants' GP. Therapist: psychiatrists with at least 5 years of experience in managing suicidal crises Type of therapy offered: supportive therapy by telephone Length of treatment: 1 telephone call at 1 or 3 months postdischarge | |
| Outcomes | Included: i) suicide reattempts according to both self report and hospital records; ii) suicide Excluded: none | |
| Notes | Sources of funding: "This study was funded by a hospital clinical research grant (PHRC98), a state region contract plan, a subsidy from the regional hospitalization agency" (p. 1245). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Patients were randomised. . . on the basis of a computer generated list of pseudo‐random numbers. We used two strata for the randomisation process: one for patients who had attempted fewer than four suicides in the past three years and one for those who had attempted more than four suicides in the past three years. For each stratum the patients were assigned by random allocation" (pp. 1241‐1242) Comment: use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: " [P]atients were allocated to a group according to the number in an opaque, sealed envelope. The allocation sequence was provided by a statistician uninvolved in the assessment of patients" (p. 1241). Study authors further note that "The allocation list was stored in tamper proof envelopes in a locked cabinet, accessible only to authorised staff" (p. 1242). Comment: Use of sealed, tamper‐proof envelopes stored in a locked cabinet would ensure adequate allocation concealment. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: "A specially trained research psychologist, blind to allocation group, assessed the outcome by telephone" (p. 1242). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "At the end of the 13 month follow‐up period we assessed all the included participants, regardless of whether their assigned telephone intervention had taken place" (p. 1243). Comment: of the 605 participants, 89 (14.7%) did not complete the intervention, and 121 (20.0%) were lost to follow‐up at 13 months for the following reasons: i) died; ii) unstated reasons. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computer generated series of random numbers Follow‐up period: 12 months N lost to follow‐up: 0/274 (0%) for repetition data | |
| Participants | Inclusion criteria: i) admitted to hospital following an attempted suicide; ii) able to understand and write Dutch; iii) living in the hospital catchment area Exclusion criteria: i) engaged in habitual wrist cutting of minor severity; ii) currently admitted as a psychiatric inpatient; iii) currently in prison; iv) diagnosed with an substance addiction; v) requires recurrent consultations with a liaison psychiatrist during a stay of more than 2 days on a somatic ward Numbers: Of the 274 participants, 140 were allocated to the experimental arm and 134 were allocated to the control arm. Profile: 57.7% (n = 158) were female, 63.9% (n = 175) were multiple repeaters, 28.1% (n = 77) were diagnosed with a mood disorder. Source of participants: patients admitted to hospital following a suicide attempt Location: Utrecht, the Netherlands | |
| Interventions | Experimental: brief psychiatric unit admission to a specialist unit for the treatment of suicide attempters for a period of 1‐4 days. Participants were then offered outpatient treatment based on Hawton and Catalan's problem‐solving approach (Hawton 1987b). Treatment specifically focused on encouraging participants to: i) discuss the reasons behind the current suicide attempt; ii) discuss these reasons with family, partner, or both if required; iii) contact the unit on discharge in the case of a suicidal crisis; iv) change their ability to cope with future problems. 24‐hour emergency access to unit was offered throughout the duration of outpatient treatment. Control: TAU. For around 25% (n = 34) this involved admission to an inpatient unit, whilst for the remaining 75% (n = 100), this involved referral to outpatient services. Therapists: 1 psychiatrist, 2 community psychiatric nurses, and 9 psychiatric nurses Type of therapy offered: problem‐solving therapy Length of treatment: not specified | |
| Outcomes | Included: i) suicide reattempts according to self report, hospital records, or both; ii) suicide; iii) compliance; iv) depression; v) hopelessness Excluded: i) anxiety; ii) sleep disorder; iii) psychiatric hospitalisation; iv) phobic anxiety; v) somatisation; vi) obsession‐compulsion; vii) interpersonal sensitivity; viii) hostility | |
| Notes | Sources of funding: "This study was supported by grant OG 92‐023 of the National Health Insurance Council (Ziekenfonds‐Raad)" (p. 40). Declaration of author interests: none stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Envelope[s] contained a number obtained from a list of random numbers generated by computer" (p. 36) Comment: Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Low risk | Quote: "The nurse on duty in the experimental ward performed the randomisation by opening the next from a series of sealed and opaque envelopes" (p. 36) Comment: Use of sealed, tamper‐proof envelopes stored in a locked cabinet would ensure adequate allocation concealment from all except the nurse on duty. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Patients assigned to the experimental treatment were informed about the experiment" (p. 36). Additionally, "patients in the control group were sent written information about the experiment" (p. 36) Comment: As patients were aware of the trial, it is likely they were also aware of which treatment arm they had been allocated to. |
| Blinding (performance bias and detection bias) | High risk | Quote: "The nurse on duty in the experimental ward performed the randomisation by opening the next from a series of sealed and opaque envelopes" (p. 36) Comment: suggests that nurses were aware of allocation. However, no details on blinding of other personnel blinding were provided. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on outcome assessor blinding provided |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All comparisons were made on an 'intention to treat' basis, regardless of how long (or even whether) patients had received the treatment assigned" (p. 37) |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using an open randomisation list Follow‐up period: 12 months N lost to follow‐up: 125/516 (24%) for repetition of SH data | |
| Participants | Inclusion criteria: i) over 15 years old; ii) resident in catchment area Exclusion criteria: i) currently receiving inpatient medical treatment Numbers: of the 516 participants, 258 were allocated to the experimental arm and 258 were allocated to the control arm Profile: 43% (n = 222) were female, 30% (n = 155) were multiple repeaters, 15% (n = 77) were diagnosed with mood disorder, 2.7% (n = 14) were diagnosed with anxiety disorder Source of participants: patients treated in an A&E department following a suicide attempt Location: Ghent, Belgium | |
| Interventions | Experimental: compliance enhancement involving home visits to those participants who did not keep to scheduled outpatient appointments in addition to TAU. Reasons for not attending appointments were discussed and the patient was encouraged to attend future treatment sessions. Control: outpatient appointments only. Non‐compliant participants did not receive home visits. Therapist: community nurse. Type of therapy offered: assertive outreach and compliance enhancement. Length of treatment: not specified. | |
| Outcomes | Included: i) repetition of SH according to self report, with collateral report from GPs, relatives or both, if the participant could not be contacted; ii) suicide; iii) compliance Excluded: none | |
| Notes | Sources of funding: "This study was supported by a grant from the National Fund for Scientific Research (NFWO, grant no. 3.0061.86)" (p. 969). Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | High risk | Quote: "Patients were randomly allocated. . . using a randomization list" (p. 964) Comment: As the numbers table was open, it is possible there may have been bias in the generation of the random sequence. |
| Allocation concealment (selection bias) | High risk | Comment: As the numbers table was open, it is possible there may have been bias in the concealment of allocation. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | High risk | Comment: no details on outcome assessor blinding were provided. However, most outcome measures, were either self reported or reported by relatives, GPs or both. Given the nature of this trial, participants, relatives, and GPs could have known group allocation. |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: Of the 516 participants, 125 (24.2%) were lost to follow‐up. Reasons given for dropouts included: i) refused follow‐up assessment (n = 97); ii) moved from catchment area without leaving a forwarding address (n = 22); iii) death following a somatic illness (n = 2); iv) admitted to hospital with a terminal illness (n = 2); v) imprisoned (n = 2). No details on whether intention‐to‐treat analyses were conducted was provided, however. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using sequentially numbered sealed envelopes Follow‐up period: 16 weeks N lost to follow‐up: 0/77 (0%) for repetition of SH data | |
| Participants | Inclusion criteria: i) aged over 16 years old Exclusion criteria: i) immediate medical or psychiatric treatment needs Numbers: Of the 77 participants, 38 were allocated to the experimental arm and 39 were allocated to the control arm. Profile: 62% (n = 48) female. 36% (n = 28) were repeaters. Mean age of 30 years. Source of participants: patients admitted to an A&E department for SH Location: York, UK | |
| Interventions | Experimental: general hospital admission excluding additional treatment or counselling. "Hospital admission consisted of little more than a bed, without further referral to other helping agencies" (p. 238). Control: discharge from hospital Therapist: none Type of therapy offered: hospital admission Length of treatment: median length of admission was 17 hours | |
| Outcomes | Included: i) repetition of SH according to GP interview, hospital records, or both; ii) suicidal ideation; iii) hopelessness Excluded: i) depression; ii) psychiatric admission; iii) time off work; iv) social isolation; v) somatic concerns; vi) daily routine; vii) social behaviour assessment schedule; viii) GP questionnaire | |
| Notes | Sources of funding: no specific sources of funding were provided for this trial. Declaration of author interests: "John Waterhouse was in receipt of a research grant from the Yorkshire Regional Health Authority" (p. 241). Other: As depression data had been combined with anxiety data, this outcome was not included in the present review. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Randomisation took place. . . using sequentially numbered sealed envelopes" (p. 237) Comment: Although it is likely the random sequence was adequately generated, without further information on the method used, this cannot be ascertained. |
| Allocation concealment (selection bias) | Low risk | Quote: "Randomisation took place. . . using sequentially numbered sealed envelopes" (p. 237) Comment: No mention of whether the envelopes were opaque or not, although they probably were. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means that personnel (e.g., hospital staff, GPs) are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | High risk | Quote: "Follow up interviews . . . were performed one week after the attempt by one of the authors. . . who was not blind to the patient's treatment group" (p. 237) |
| Incomplete outcome data (attrition bias) | Unclear risk | Comment: Of the 77 participants, 4 (5.2%) dropped out after 1 week and a further 21 (28.4%) dropped out by 16 weeks. No details provided on whether intention‐to‐treat analyses were conducted, however. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a computerised randomisation programme Follow‐up period: 3, 6, and 12 months N lost to follow‐up: 77/239 (32.2%) at 3‐month follow‐up; 123/239 (51.5%) at the 6‐month follow‐up; 151/239 (63.2%) at the 12‐month follow‐up | |
| Participants | Inclusion criteria: i) older than 15 years; ii) admitted to emergency departments following a suicide attempt; iii) have at least 1 contact person to provide collateral reports on suicidal behaviour, etc; iv) able to understand the trial procedures; v) able to provide written informed consent Exclusion criteria: none stated Numbers: Of the 239 participants, 82 were allocated to the cognitive therapy intervention arm, 80 were allocated to the telephone intervention, and 77 were allocated to the control arm. Profile: 76.1% (n = 182) were female; 45.2% (n = 108) were diagnosed with any psychiatric disorder Source of participants: patients admitted to emergency departments following a suicide attempt Location: Shenyang, Liaoning Province, China | |
| Interventions | Experimental: there were 2 experimental arms in this trial: i) cognitive therapy, and ii) telephone intervention. Cognitive therapy involved sessions of cognitive therapy as well as supporting patients to reconnect with family and friends. The telephone intervention involved psychological support based on reassurance and emphatic reasoning, and collaborative problem‐solving therapy. Control: " [P]atients in the control group did not receive any interventions" (p. 109). Therapist: Therapists had more than 5 years clinical work experience. Type of therapy offered: i) cognitive‐behavioural therapy; ii) telephone contact Length of treatment: 3 months | |
| Outcomes | Included: i) repetition of SH; ii) suicide; iii) suicidal ideation; iv) depression Excluded: i) quality of life | |
| Notes | Sources of funding: "This project was part of the 'Small Grants Program to Improve the Quality and Implementation of Suicide Research in China' which was supported by the China Medical Board of New York (grant number 05‐813)" (p. 113). Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "[P]articipants . . . were randomly assigned. . . using a computerized randomization program" (p. 109). Comment: Use of a computerised randomisation sequence is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details on blinding of outcome assessors provided |
| Incomplete outcome data (attrition bias) | Low risk | Quote: "All analyses were conducted using the intent‐to‐treat (ITT) principle. . . " (p. 110). |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation by asking participants to choose between 2 similar envelopes Follow‐up period: 8 months N lost to follow‐up: 0/30 (0%) for repetition of SH data | |
| Participants | Inclusion criteria: i) female; ii) aged 18‐40 years; iii) diagnosed with borderline personality disorder; iv) history of repetitive SH with at least 1 episode during the month before enrolment Exclusion criteria: i) diagnosed with comorbid psychosis; ii) judged to be at an elevated risk of suicide; iii) diagnosed with substance abuse; iv) history of attempted suicide (only those engaging in repetitive SH were eligible for inclusion in this trial) Numbers: Of the 30 participants, 15 were allocated to the experimental arm and 15 to the control arm. Profile: 100% (n = 30) were female Source of participants: recruited from the community via advertisements in local newspapers, clinical services at a hospital, and from individuals participating in a longitudinal study Location: Boston, MA, USA | |
| Interventions | Experimental: manual assisted cognitive treatment involving of 6 sessions aimed at evaluation an attempt, developing crisis skills problem‐solving skills, developing cognitive techniques for emotional, and negative thinking management, and outlining relapse prevention strategies Control: TAU Therapists: primary investigator acted as the therapist Type of therapy offered: cognitive behavioural therapy Length of treatment: 2 months | |
| Outcomes | Included: i) repetition of SH according to self report; ii) suicidal ideation; iii) suicide Excluded: i) severity of SH | |
| Notes | Souces of funding: "This study was supported by a Young Investigator Aware from the Borderline Personality Disorder Research Foundation (I.W.)" (p. 482). Declaration of author interests: no details provided Other: All participants were also simultaneously participating in additional treatment throughout the duration of this trial. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Subjects were randomly assigned" (p. 485) Comment: Correspondence with authors further clarified that "subjects were asked to choose between 2 similar envelopes containing either manual assisted cognitive behaviour therapy or non‐manual assisted cognitive behaviour therapy." |
| Allocation concealment (selection bias) | Low risk | Comment: correspondence with authors clarified that subjects choose between 2 similar envelopes. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Low risk | Quote: ". . . interviewers were blind to baseline ratings and to participants' group allocation at post‐treatment assessments and 6‐month follow‐up" (p. 487). |
| Incomplete outcome data (attrition bias) | Low risk | Quote: Although "[a]ll MACT participants completed 6 sessions of MACT. Two TAU group participants were not available for the post‐treatment assessments (p. 485). Nevertheles, "[a]ll participants were interviewed at the 6 months follow up" (p.485), suggesting that intention‐to‐treat analyses were undertaken. |
| Selective reporting (reporting bias) | Unclear risk | Comment: We had to request data on suicides from authors, suggesting that selective reporting bias may have been present. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
| Study characteristics | ||
| Methods | Allocation: randomisation using a table of random numbers Follow‐up period: 4 months N lost to follow‐up: 1/120 (1%) for repetition of SH data | |
| Participants | Inclusion criteria: i) over 16 years old Exclusion criteria: i) student living in university accommodation; ii) resident in a caregiving institution or institutionalised at the time of the index episode of SH Numbers: Of the 120 participants, 63 were allocated to the experimental arm and 57 to the control arm. Profile: 60% (n = 72) were multiple repeaters Source of participants: patients admitted to an A&E department following an episode of SH Location: Pittsburgh, PA, USA | |
| Interventions | Experimental: special outreach programme involving a community mental health team contacting participants immediately after discharge to arrange weekly/bi‐weekly home visits Control: TAU involving a psychiatric consultation at request of the treating physician. Participants were also given a next day appointment for evaluation at the community mental health team centre. Any further contact after discharge was at the participant's request. Therapist: 4 nurses, 3 social workers, and 2 community workers Type of therapy offered: special outreach involving a variety of treatments Length of treatment: 4 months | |
| Outcomes | Included: i) repetition of SH according to one or more of: self report, hospital records, collateral informant report Excluded: i) extent of follow‐up coverage; ii) type and frequency of contacts; iii) purposive accidents; iv) excessive use of alcohol; v) drug misuse | |
| Notes | Sources of funding: "This investigation was supported by Research Grant MH19491 from the National Institute of Mental Health" (p. 17). Declaration of author interests: no details provided | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Quote: "Random assignment was worked out in advance from a table of random numbers" (p. 20) Comment: Use of a random numbers table is likely to have minimised the role of bias in the generation of the randomisation sequence. |
| Allocation concealment (selection bias) | Unclear risk | Comment: no details on allocation concealment provided |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of this trial means that participants could have known to which group they had been allocated. |
| Blinding (performance bias and detection bias) | High risk | Comment: The nature of the trial means personnel are likely to have known which participant was receiving which treatment. |
| Blinding (performance bias and detection bias) | Unclear risk | Comment: no details provided on outcome assessor blinding |
| Incomplete outcome data (attrition bias) | High risk | Comment: of the 120 participants, 6 (9.5%) in the experimental arm and 26 (45.6%) in the control arm were lost to follow‐up for unstated reasons. Intention‐to‐treat analyses were not attempted, however. |
| Selective reporting (reporting bias) | Unclear risk | Comment: no reason to suspect that all outcomes were not measured; however, in the absence of the trial protocol, this cannot be ascertained. |
| Other bias | Low risk | Comment: no other apparent sources of bias |
A&E: accident and emergency; BPD: borderline personality disorder; CBT: cognitive behavioural therapy; DBT: dialectical behavioural therapy; DSM‐IV (TR): Diagnostic and Statistical Manual of Mental Disorders, fourth edition (text revision); ITT: intention‐to‐treat; MACT: manual‐assisted cognitive therapy; NSSI: non‐suicidal self‐injury; PST: problem‐solving therapy; PTSD: post‐traumatic stress disorder; SCID‐II: Structured Clinical Interview for DSM‐IV Axis II Personality Disorders; SH: self‐harm; SSRI: selective serotonin reuptake inhibitors; TAU: treatment as usual.
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
| Participants were not required to have engaged in SH prior to trial entry. | |
| Non‐randomised clinical trial | |
| Correspondence with authors suggested bias in both allocation and allocation concealment to the intervention and control groups. | |
| Method of allocation to intervention and control groups unclear | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Reports on 5‐year outcomes, rather than within the 2‐year time frame | |
| Non‐randomised clinical trial | |
| Correspondence with authors revealed that information on non‐fatal repetition of SH could not be disaggregated from information on completed suicide. Additionally, the study did not collect data on the secondary outcomes included in this review. | |
| Correspondence with authors revealed that participants were alternately allocated to the intervention and control groups. | |
| Database of RCTs | |
| Correspondence with authors confirmed that not all participants engaged in self‐harm in the 6 months prior to randomisation. | |
| Non‐randomised clinical trial | |
| Participants were not required to have engaged in SH prior to trial entry | |
| Participants could have engaged in SH at any point within 1 year prior to trial entry, rather than within 6 months. | |
| Participants could have engaged in SH at any point, rather than within 6 months. | |
| Conference proceedings | |
| Participants not required to have engaged in SH prior to trial entry | |
| Review | |
| Non‐randomised clinical trial | |
| RCT of a psychosocial intervention for SH patients that only presents data from the intervention arm | |
| Non‐randomised clinical trial | |
| Conference proceedings | |
| Letter to the editor | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Letter to the editor | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| RCT of a pharmacological intervention for SH patients | |
| Participants were not required to have engaged in SH prior to trial entry | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial in which only 3 participants were enrolled | |
| Participants not required to have engaged in SH prior to trial entry | |
| Correspondence with authors confirmed that not all participants were randomised to the intervention or control groups; some chose to receive the intervention treatment. | |
| Non‐randomised clinical trial | |
| Correspondence with authors confirmed that not all participants engaged in SH in the 6 months prior to randomisation. | |
| Review | |
| Non‐randomised clinical trial | |
| Review | |
| Participants were not required to have engaged in SH prior to trial entry | |
| Not all participants were randomised to the intervention or control groups; some chose to receive the intervention treatment. | |
| Participants were not required to have engaged in SH prior to trial entry | |
| Non‐randomised clinical trial | |
| Non‐randomised clinical trial | |
| Participants could have engaged in SH at any point within 1 year of trial entry, rather than within 6 months. |
RCT: randomised controlled trial; SH: self‐harm.
Characteristics of studies awaiting classification [ordered by study ID]
| Methods | Allocation: 2‐arm, parallel group randomisation Design: single centre (outpatient psychiatric clinic) Setting: community Follow‐up period: 52 weeks Location: Copenhagen, Denmark |
| Participants | Males and females, 18‐65 years of age, meeting 2 or more criteria for a diagnosis of borderline personality disorder according to the DSM‐IV, who made a suicide attempt within 1 month of inclusion into the trial, and are able to provide informed consent |
| Interventions | Participants randomised to the experimental group will receive either 16 weeks of dialectical behaviour therapy (DBT) or 16 weeks of Collaborative Assessment and Management (CAMS) of suicidality alongside CAMS‐informed supportive psychotherapy |
| Outcomes | Primary outcome: number of subsequent episodes of self‐harm and suicide attempts at 17, 28, and 52 weeks follow‐up Secondary outcomes: scores on the Hamiliton Depression Rating Scale (HDRS), BDI, BSSI, the Suicide Attempt Self Injury Interview (SASII), Beck Hopelessness Scale (BHI), Barratt Impulsivity Scale (BIS), the Zanarini Borderline Personality Scale (ZBPS), the State Trait Anger Scale (STAS), and Rosenberg's Self Esteem Scale measured at 16, 28, and 52 weeks follow‐up |
| Notes | Dr. Kate Andreasson very kindly provided unpublished information relating to this trial. |
| Methods | Allocation: individual randomisation Design: single centre Setting: hospital Location: Kuala Lumpur, Malaysia |
| Participants | Males and females admitted to Kuala Lumpur Hospital following an episode of self‐harm (ICD‐10 X60–X84, intentional self‐harm13) between 1 March 2010 and 28 February 2011. |
| Interventions | Implementation intentions to reduce suicidal ideation and behaviour. All participants were initially presented with a brief statement designed to encourage them to plan not to self‐harm: ‘We want you to plan not to self‐harm. Research shows that you are much more likely to be successful in your intention not to self‐harm if you can identify critical situations and appropriate responses’. Following this statement, participants were randomised to one of three groups: (i) volitional help sheet with implementation intentions (11 critical situations and 11 appropriate responses) (N=75); (ii) self‐generating implementation intentions, without help (N=78); (iii) a control condition (the volitional help sheet, but no instruction on how to form implementation intentions, participants were simply asked to identify critical situations and appropriate responses that might be useful to them) (N=73). |
| Outcomes | Primary outcomes: suicidal ideation and behaviour (revised Suicidal Behaviours Questionnaire); depression (BDI‐II); motivation to avoid self‐harm. |
| Notes | Personal communication between KH and Rory O'Connor |
| Methods | Allocation: individual randomisation using shuffled sealed envelopes. Design: single centre (hospital‐based recruitment). Setting: emergency unit of a university general hospital. Location: Bern, Switzerland. |
| Participants | Males and females, 18 years of age and older, admitted to the emergency unit of a university general hospital following a suicide attempt for which there is evidence of an intent to die. Those with a history of multiple episodes of self‐harm (i.e., indicative of probable borderline personality disorder pathology), serious cognitive impairment, psychosis, insufficient ability to communicate in German, or those resident outside of the hospital catchment area will be excluded from participation. |
| Interventions | Individuals randomised to the intervention group will receive between three and four weekly sessions of between 60‐90 minutes in length of face‐to‐face psychosocial therapy delivered according to the ASSIP manual (Gysin‐Maillart 2013; Michel 2015) involving a narrative interview, cognitive restructuring, and crisis safety planning. Additionally, participants in the intervention group will receive one letter every three months for a total of 24 months reminding them of the importance of safety planning during times of crisis. |
| Outcomes | Primary outcomes: suicide reattempts according to hospital records during the 24 month follow‐up period. Secondary outcomes: scores on the 11‐item Penn Helping Alliance Questionnaire, the Beck Depression Inventory, and the Beck Scale for Suicidal Ideation during the 24 month follow‐up period. |
| Notes |
| Methods | Allocation: randomisation using a computerised adaptive minimisation procedure whereby participants were matched using 5 primary prognostic variables: i) age; ii) number of prior 'suicide attempts'; iii) number of prior NSSI episodes; iv) number of psychiatric hospitalisations within the past year; v) depression severity Follow‐up period: 12 months N lost to follow‐up: 0/99 (0%) for repetition of NSSI and 'suicide attempts' |
| Participants | Inclusion criteria: i) 18‐60 years; ii) female; iii) met criteria for borderline personality disorder; iv) at least 2 'suicide attempts' or episodes of NSSI over the past 5 years; v) at least 1 'suicide attempt' or episode of NSSI within the 8 weeks prior to entering the study; vi) at least 1 'suicide attempt' in the previous year. Due to difficulties in reaching recruitment targets, the authors relaxed inclusion criteria towards the end of the recruitment period to include 1 participant who had engaged in an episode of NSSI in the 8‐week period prior to entering the study but who did not have a prior history of NSSI and 5 participants who did not have a history of repeated episodes of NSSI but who did make a 'suicide attempt' within the past year. Exclusion criteria: i) met criteria for a current psychotic or bipolar disorder; ii) diagnosed with a seizure disorder requiring the use of medication; iii) currently undergoing treatment for another life‐threatening condition (e.g., anorexia nervosa); iv) an IQ score of less than 70 on the Peabody Picture Vocabulary Test‐Revised Numbers: of the 99 participants 33 were allocated to the DBT + skills training arm, 33 were allocated to the DBT + individual therapy arm, and 33 were allocated to the DBT standard protocol arm. Profile: 99 (100%) were female, 95 (95.9%) had a lifetime diagnosis of major depression, 87 (87.9%) had a lifetime diagnosis of any anxiety disorder, and 69 (69.7%) had a lifetime diagnosis of a substance use disorder. Source of participants: healthcare practitioners Setting: Seattle, WA, USA |
| Interventions | Experimental: This trial involved 2 experimental arms. The first, 'DBT + skills training', incorporated a manualised standard case management protocol, group‐based skills training sessions, and telephone coaching as required; it was designed to resemble the DBT standard protocol with the omission of all sessions of individual‐based psychotherapy. The second, 'DBT + individual therapy', incorporated individual‐based therapy, an activity‐based support group, and telephone coaching as required; it was designed to resemble the DBT standard protocol with the omission of all sessions of group‐based skills training. Control: DBT standard protocol incorporating sessions of individual‐based psychotherapy, group‐based skills training, and telephone coaching as required Therapists: specially trained to provide either experimental or control therapy Type of therapy offered: dialectical behaviour therapy with skills training and dialectical behaviour therapy with individual‐based psychotherapy Length of treatment: 1 year |
| Outcomes | To be included: i) repetition of SH (requires correspondence from study authors as to whether it is possible to aggregate episodes of NSSI and 'suicide reattempts'); ii) depression; iii) suicidal ideation; iv) adherence with treatment Excluded: i) anxiety; ii) importance of reasons for living |
| Notes |
BDI: Beck Depression Inventory; BSSI: Beck Scale for Suicidal Ideation; DBT: dialectical behaviour therapy; MINI: Mini International Neuropsychiatric Interview; NSSI: non‐suicidal self‐injury; TAU: treatment as usual.
Characteristics of ongoing studies [ordered by study ID]
| Study name | Text message intervention to reduce repeat self‐harm. Trial registration number: NCT01823120. |
| Methods | Allocation: single blind, parallel assignment, randomisation Design: single centre Setting: community Location: Dublin, Republic of Ireland Follow‐up period: 3 months |
| Participants | Inclusion criteria: males and females, 18 years of age and older, presenting to the emergency department following an episode of self‐harm, with a mobile phone and familiar with text messaging Exclusion criteria: those who do not provide consent to participate, who do not have a mobile phone or are unfamiliar with text messaging, who are admitted to psychiatric inpatient facilities following assessment in the emergency department, who require admission to a medical ward for more than 48 h, or who are unavailable at any point during the 3‐month follow‐up period |
| Interventions | Those randomised to the intervention arm will receive daily text messages for 1 month, followed by 1 message every 2 days for the second month, followed by 1 message per week for the third month following discharge from the emergency department. Text messages will target the relief of mood symptoms and will provide advice on strategies for coping with suicidal thoughts. Messages will also provide patients with a mobile phone number for the Samaritans. All messages will encourage participants to contact the Samaritans in times of crisis. |
| Outcomes | Primary outcome measures: proportion of patients repeating self‐harm and scores on the Suicide Behaviors Questionnaire Secondary outcome measures: number of repeat episodes of self‐harm per person, scores on the Modified Scale for Suicidal Ideation, scores on the Positive and Negative Suicide Ideation Inventory, scores on the Beck Hopelessness Scale, and scores on the Global Assessment of Functioning |
| Starting date | March 2013. End date: March 2014. |
| Contact information | Name: Dr Vincent Agyapong. Affiliation: Department of Psychiatry, Trinity College Dublin, Republic of Ireland email: [email protected] |
| Notes | We made three attempts to contact Dr Agyapong to confirm these details; however, we received no response. We therefore extracted information for this trial from the ClincialTrials.gov record. |
| Study name | Treatment for Non‐Suicidal Self‐Injury in Young Adults (T‐SIB). Trial registration number: NCT01018433. |
| Methods | Allocation: Single‐blind, parallel assignment, randomised Design: single centre Setting: outpatient clinic Location: Bronx, NY, USA Follow‐up period: 3 months |
| Participants | Inclusion criteria: males and females, aged 18‐29, with a history of engaging in NSSI (with or without an urge to self injure) within the month prior to randomisation Exclusion criteria: those with psychotic symptomatology or severe suicidal ideation |
| Interventions | Participants randomised to the experimental group will receive 9 sessions of therapy to reduce both the frequency and severity of non‐suicidal self‐injury. |
| Outcomes | Primary outcome measures: frequency and severity of NSSI Secondary outcome measures: scores on the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the McLean Screening Instrument for Borderline Personality Disorder, the College Student Inventory, the Social Problem Solving Inventory‐Revised (SPSI‐R), the Symptom Checklist‐90‐Revised (SCL‐90‐R), and the University of Rhode Island Change Assessment (URICA) |
| Starting date | September, 2008.End date: July, 2013. |
| Contact information | Name: Prof. Margaret Andover.Affiliation: Department of Psychology, Fordham University.email:[email protected] |
| Notes | We made three attempts to contact Prof Andover to confirm these details; however, we received no response and so were unable to confirm whether all participants either engaged in deliberate self‐harm or made a suicide attempt within six months prior to randomisation. Additionally, we were unable to confirm whether the trial was ongoing. We extracted information for this trial from the ClinicalTrials.gov record. |
| Study name | SIAM: Suicide Intervention Assisted by Messages. Trial registration number: NCT02106949. |
| Methods | Allocation: randomised. Design: multicentre. Setting: recruitment from hospital settings, treatment provided in the community. Location: Brest, Rennes, Nates, Lille, Angers, Tours, and Vannes, France. Follow‐up period: 6 and 13 months. |
| Participants | Inclusion criteria: males and females, 18 years of age or older, who attempt suicide and are admitted to the emergency department and/or psychiatric unit of one of seven participating hospitals, who are hospitalised for no more than 7 days, and are able to be contacted by mobile telephone. |
| Interventions | Those randomised to the intervention group will receive 9 text messages, one within 48 hours of discharge, one a days 8 and 15, and one at months 1,2,3,4,5, and 6. Content of these messages will address validation, recall of the discharge treatment agreement, and outreach via a continuing care intervention program. Messages will also provide participants with information on their treating doctor's name and contact information (GP or psychiatrist as appropriate), as well as dates of scheduled appointments (as applicable). Information on a crisis telephone number, available 24/7, will also be included. |
| Outcomes | Primary outcomes: number of subsequent suicide attempts at the 6 month follow‐up assessment. Secondary outcomes: number of subsequent suicide attempts at the 13 month follow‐up assessment, number of deaths by suicide at the 6 and 13 month follow‐up assessments, and the number self‐reporting suicidal ideation at the 6 and 13 month follow‐up assessments. |
| Starting date | June, 2014. Anticipated end date: not specified. |
| Contact information | Name: Dr Sofian Berrouiguet (Principal Investigator) Affiliation: Hôspital Cavale Blanche, Brest, France. email:[email protected] |
| Notes |
| Study name | Effectiveness of Standard Emergency Department Psychiatric Treatment Associated With Treatment Delivery by a Suicide Prevention Center Trial registration number: NCT00641498. |
| Methods | Allocation: randomised Design: multicentre Setting: dedicated outpatient suicide prevention centres Location: Toulouse, France Follow‐up period: 2 years |
| Participants | Inclusion criteria: males and females, 18 years of age and older, who have made a suicide attempt by self‐poisoning, who have a Glasgow score of 15, and who are currently receiving standard psychiatric treatment Exclusion criteria: unable to speak French; admitted to inpatient facilities will be excluded from participation |
| Interventions | Participants randomised to the intervention arm will receive sessions of individual supportive psychotherapy delivered in a dedicated outpatient suicide prevention centre. No further details on the content, number, or duration of these sessions is reported. Proposed N= 405 |
| Outcomes | Outcome measures: frequency of subsequent suicidal behaviour and death by suicide during the 2‐year follow‐up period |
| Starting date | March, 2007. End date: October, 2011. |
| Contact information | Name: Dr. Philippe Birmes. Affiliation: University Hospital, Toulouse, France. email:[email protected] |
| Notes | We made 3 attempts to contact Dr Birmes to confirm these details; however, we received no response and so were unable to confirm whether all participants either engaged in deliberate self‐harm or made a suicide attempt within 6 months prior to randomisation. Additionally, we were unable to confirm whether the trial was ongoing. We extracted information for this trial was extracted from the ClinicalTrials.gov record. |
| Study name | Community‐based cognitive therapy for suicide attempters Trial registration number: NCT00081367. |
| Methods | Allocation: randomised Design: multicentre Setting: recruitment from hospital settings, treatment provided in community mental health clinics Location: Philadelphia, PA, USA Follow‐up period: unclear |
| Participants | Inclusion criteria: males and females, 16 years of age or older, who attempt suicide within 48 h of presenting to an emergency department or trauma care unit, who are able to speak English, and are able to understand the nature of the trial, and who provide written informed consent |
| Interventions | Those randomised to the intervention group will receive 10 weekly sessions of cognitive therapy in addition to enhanced usual care. |
| Outcomes | Primary outcomes: number of subsequent suicide attempts, scores on a measure of suicidal ideation, scores on a measure of depression, and scores on a measure of hopelessness |
| Starting date | April, 2004 Data collection completed: September 2009 |
| Contact information | Name: Prof Gregory Brown (Principal Investigator) Affiliation: Department of Psychiatry, University of Pennsylvania email: [email protected] |
| Notes | Prof Gregory Brown very kindly provided unpublished information relating to this trial. |
| Study name | MIDSHIPS: Multicentre Intervention Designed for Self‐Harm using Interpersonal Problem‐Solving. Trial registration number: ISRCTN54036115. |
| Methods | Allocation: stratified block random allocation with minimisation Design: single‐centre (hospital‐based recruitment by a specialist Self Harm Assessment Team within the Leeds and York NHS Trust) Setting: clinic rooms, GP practices, or both Location: Leeds and York, UK |
| Participants | Males and females, 18 years of age and older, who present to hospital following an episode of self‐harm are eligible to participate in this trial. Both first time self‐harmers and those with more extensive self‐harming histories will be included. Individuals diagnosed with any psychiatric disorder are also eligible to participate. N = 60 |
| Interventions | Individuals randomised to the intervention group will receive 4‐6 one‐hour weekly problem‐solving therapy sessions aimed at helping patients to identify problems and to provide them with strategies for resolving these and future problems more constructively. |
| Outcomes | Primary outcomes: repetition of self‐harm necessitating hospital admission within 6 months of randomisation, attendance at therapy sessions as measured by the Health and Social Care Information Centre, scores on the General Health Questionnaire and the EuroQol‐5D, and other health economics data |
| Starting date | January, 2012. Completed: July, 2015. |
| Contact information | Name: Dr David Owens (Principal Investigator) Affiliation: University of Leeds. email:[email protected] |
| Notes | Dr David Owens very kindly provided unpublished information relating to this trial. Additionally, Dr Owens provided the following notes pertaining to the this trial: "Funded by the National Institutes of Health Research (NIHR) Research for Patient Benefits (RfPB) program. The planned application for the full (multicentre) trial (will be made) to the Health Technology Assessment (HTA) (program) in late 2014." |
| Study name | ENGAGE ‐ Meeting mental health needs of complex comorbid patients attending A&E following a suicide attempt. A pilot study Trial registration number: NCT00980824. |
| Methods | Allocation: single blind randomisation Design: single‐centre (community) Setting: postdischarge patients followed up in the community Follow‐up period: 3 months Location: Glasgow, UK |
| Participants | Inclusion criteria: males and females, 18 years of age and older, who were admitted to a general hospital following an episode of self‐harm or a suicide attempt, and who score above the threshold for personality disorder using the SAPAS will be included in this trial. Those with substance misuse, defined as scoring above the threshold for substance misuse according to the AUDIT or the DAST, will not be excluded from participation. N= 20 |
| Interventions | Those randomised to the experimental group will receive 6 sessions of Manual‐Assisted Cognitive Therapy (MACT), a brief focused therapy to address self‐harm and to promote engagement with services. ENGAGE is designed to help patients to identify problems that lead to self‐harming behaviour or attempted suicide and to assist patients in using problem‐solving therapy to resolve these problems. Emphasis will also be placed on encouraging engagement and on facilitating contact with specialist substance misuse, personality disorder treatment, or both, as appropriate. |
| Outcomes | Primary outcomes: scores on measures of depressed mood, anxiety, and suicidality at baseline and after 3 months of follow‐up |
| Starting date | November 2009 End date: December 2010 |
| Contact information | Name: Prof Kate Davidson (Principal investigator) Affiliation: University of Glasgow email: [email protected] |
| Notes | Prof Davidson kindly very kindly provided unpublished information relating to this trial. Additionally, Prof Davidson provided the following notes pertaining to this trial: "Pilot study to assess feasibility to recruit a sample of these complex patients to a randomised controlled trial of MACT following an index episode of self‐harm. There is preliminary support that MACT could be an acceptable and effective intervention in patients with personality disorder and substance misuse." |
| Study name | Ottawa Suicide Prevention in men pilot study (OSSUPilot): A cluster‐randomised trial of a smart phone assisted problem‐solving therapy in men who present to hospital with intentional self‐harm. Trial Registration Number: NCT02718248. |
| Methods | Allocation: cluster randomisation with emergency departments being the unit of randomisation Design: multicentre (hospital emergency department facilities). Setting: postdischarge patients followed up in the community. Follow‐up period: 1 year. Location: Ontario, Canada. |
| Participants | Inclusion criteria: males, 18 years of age and older, presenting to hospital‐based emergency department facilities following an episode of intentional self‐harm Exclusion criteria: females, and those younger than 18 years N expected: 1200 participants: 600 in each arm |
| Interventions | Participants randomised to the intervention group will receive 6 sessions of face‐to‐face problem‐solving therapy, 1 additional follow‐up session, and smartphone assisted problem‐solving therapy embedded in a quality improvement programme (CHESS app) over an approximate 2‐month follow‐up period. |
| Outcomes | Primary outcome: re‐presentation to hospital for any reason over a 1‐year follow‐up period Secondary outcomes: re‐presentation to hospital for intentional self‐harm over a 1‐year follow‐up period, suicide |
| Starting date | April 2016 Proposed End Date: September 2018 |
| Contact information | Name: Dr Simon Hatcher (Principal investigator) Affiliation: University of Ottawa email: [email protected] |
| Notes | Dr Hatcher very kindly provided unpublished information relating to this trial. |
| Study name | Efficacy of dialectical behavior therapy in patients with borderline personality disorder. Trial registration number: NCT01952405. |
| Methods | Allocation: randomised Design: single centre (hospital‐based) Setting: hospital Location: Taipei, Taiwan |
| Participants | Inclusion criteria: males and females, aged 18‐60, meeting DSM‐IV criteria for borderline personality disorder, and who engaged in at least 2 episodes of suicidal or non‐suicidal self injurious behaviour in the past 5 years with at least 1 episode occurring in the 3 months preceding randomisation Exclusion criteria: those diagnosed with bipolar I disorder, delirium, dementia, mental retardation, or a diagnosis of substance dependence within the preceding 30 days |
| Interventions | Participants randomised to the intervention group will receive sessions of dialectical behaviour therapy over a 12‐month follow‐up period. |
| Outcomes | Primary outcome: frequency of suicide attempts as measured by the Suicide Attempt Self Injury Interview at 4, 8, and 12 months Secondary outcomes: scores on the Borderline Symptom Checklist (BSL‐23), the Patient Health Questionnaire (PHQ‐9), the SCL‐90‐R, BSSI, BHS, Quality of Life Enjoyment and Satisfaction Questionnaire‐Short Form (Q‐LES‐Q SF), the Clinical Global Impressions‐Severity (CGI‐S) and Improvement (CGI‐I), and the Brief Disability Questionnaire (BDQ) at 4, 8, and 12 months |
| Starting date | September 2013. Proposed End Date: August 2016. |
| Contact information | Name: Hui‐Chun Huang (Assistant Investigator) Affiliation: Mackay Memorial Hospital email: [email protected] |
| Notes | Hui‐Chun Huang very kindly provided unpublished information relating to this trial. |
| Study name | Commitment and Motivation in a Brief DBT Intervention for Self Harm. Trial registration number: NCT02354183. |
| Methods | Allocation: single blind randomisation Design: single‐centre Setting: centre for addiction and mental health Location: Canada |
| Participants | Inclusion criteria: males and females, with borderline personality disorder, 18‐80 years of age, with at least 3 self‐harm episodes (either suicidal or non‐suicidal) in the past 5 years, including at least 1 in the past eight weeks. N expected: 120 Exclusion criteria: evidence of organic brain syndrome or mental retardation |
| Interventions | A 1‐hour orientation session consisting of DBT commitment strategies plus psychoeducation. Therapists will also use commitment strategies to discuss goals related to self‐harm. The psychoeducation will consist of information about DBT's biosocial theory and about why people self‐harm. All participants will complete a DBT skills training group after their orientation. |
| Outcomes | Primary outcome: change in autonomous and controlled motivation (Autonomous and Controlled Motivation for Treatment Questionnaire) Secondary outcomes: change in frequency and severity of self‐harm behaviour (Deliberate Self‐Harm Inventory) |
| Starting date | April 2015 Proposed End Date: April 2016 |
| Contact information | Name: Michelle Leybman Affiliation: Centre for Addiction & Mental Health, Canada Email: [email protected] |
| Notes |
| Study name | Effect of Psychosocial Treatment by the Case Manager in Patients After a Suicide Attempt. Trial registration number: NCT00664872. |
| Methods | Allocation: single blind randomisation Design: single centre, hospital‐based intervention Setting: hospital Follow‐up period: 6 and 12 months Location: Taipei, Taiwan |
| Participants | Inclusion criteria: males and females, 18 years of age and older, who engaged in at least 1 episode of self‐harm within 6 months prior to randomisation |
| Interventions | Participants randomised to the intervention group will receive 6 sessions of a proactive psychosocial intervention for a 4‐month period. Each session will last approximately 30 min and will consist of telephone or face‐to‐face contact with the case manager at regular, scheduled intervals or when clinically necessary. Psychotherapy will consist of both cognitive‐behavioural and problem‐solving therapy and will be delivered by trained psychologists. |
| Outcomes | Primary outcomes: the proportion of patients who self‐report a subsequent episode of self‐harm or a suicide attempt at the 6‐ and 12‐month follow‐up and the number of suicides at the 6‐ and 12‐month follow‐up Secondary outcomes: treatment attendance and adherence at the 6‐ and 12‐month follow‐up periods, types and number of contacts with healthcare services at the 6‐ and 12‐month follow‐up periods, scores on suicidal ideation as measured by the BSSI at the 6‐month follow‐up period, scores on depression as measured by the HRSD, and the 21‐item BDI over the 6‐month follow‐up period, and patient satisfaction with treatment at the 6‐ and 12‐month follow‐up assessments |
| Starting date | August, 2007. End date: July, 2008. |
| Contact information | Name: Dr. Shen‐Ing Liu. Affiliation: Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan. email:[email protected] |
| Notes | Dr Liu very kindly provided unpublished information relating to this trial. |
| Study name | DBT for Chronically Self‐harming Individuals With BPD: Evaluating the Clinical &Cost Effectiveness of a 6 mo. Treatment (FASTER‐DBT). Trial registration number: NCT02387736. |
| Methods | Allocation: single blind randomisation (outcomes assessor) Location: Greater Toronto or Vancouver area, Canada |
| Participants | Inclusion criteria: males and females, aged 18‐40 years, diagnosed with borderline personality disorder, with at least 2 self‐harm episodes (either suicidal or non‐suicidal) in the past 5 years, including at least 1 in the past 8 weeks; with absence of 8 or more standard weeks of DBT in the past year. Exclusion criteria: meets the DSM‐IV criteria for a psychotic disorder; with an IQ of less than 70; with chronic or serious physical health problem requiring hospitalization within the next year. N expected: 240 |
| Interventions | Compare 6 months v 12 months of DBT. |
| Outcomes | Primary outcome: change in frequency and severity of suicide and self‐harm behaviours over time as measured by the Suicide Attempt Self‐Injury Interview (SASII) Secondary outcomes: changes in health care use as measured by the Treatment History Interview‐2 (THI‐2); general functioning as measured by the Euroqol‐5D; BPD symptoms as measured by the Borderline Symptom List‐23 (BSL‐23); general psychopathology and symptoms, as measures by the Symptom Checklist 90 Revised (SCL‐90R); anger as measured by the State‐Trait Anger Expression Inventory‐2 (STAXI‐2); depression as measured by the Beck Depression Inventory‐II (BDI‐II); interpersonal functioning as measured by the Inventory of Interpersonal Problems‐64 (IIP‐64) |
| Starting date | February 2015 End date: March 2019 |
| Contact information | Name: Shelly McMain Affiliation: Centre for Addiction and Mental Health, Simon Fraser University email: not given – contact: [email protected] |
| Notes |
| Study name | Improving Care Provided to Patients Treated in a Level 1 Trauma Center Post‐suicide Attempt. Trial registration number: NCT01355848. |
| Methods | Allocation: single blind randomisation Design: single centre (hospital‐based), pre‐post design Setting: acute inpatient medical setting Location: Seattle, WA, USA |
| Participants | Inclusion criteria: males and females, of any age, who are admitted to a medical or surgical ward following a suicide attempt. Those with psychiatric diagnoses will not be excluded from participation. |
| Interventions | Those randomised to the experimental group will receive a brief intervention consisting of a stepped care protocol, including building rapport, functional analysis of suicidal behavior, and crisis planning for medically admitted suicide attempt survivors in addition to usual care. |
| Outcomes | Primary outcome: scores on the Patient Satisfaction Questionnaire post‐intervention Secondary outcomes: scores on the BSSI, Self Injury, Readiness to Change, and Reasons for Living scales post‐intervention |
| Starting date | May, 2011. End date: June, 2013. |
| Contact information | Name: Prof. Stephen O'Connor (PI). Affiliation: Western Kentucky University. email:[email protected] |
| Notes | Prof Stephen O'Connor very kindly provided unpublished information relating to this trial. |
| Study name | A help sheet to reduce self‐harm among people admitted to hospital for self‐harm. Trial registration number: ISRCTN99488269. |
| Methods | Allocation: randomised Design: single centre (hospital based) Setting: hospital Location: Edinburgh, Scotland |
| Participants | Inclusion criteria: males and females, 16 years or older, admitted to the Royal Infirmary of Edinburgh with self‐harm, who have a history of prior self‐harm including both hospital‐treated and non‐hospital‐treated episodes, and those with suicidal intent associated with the present attempt necessitating admission to the Royal Infirmary of Edinburgh. Exclusion criteria: those under 16 years of age, with no history of self‐harming behaviour prior to the present episode, those with no reported suicidal intent associated with the present episode, those unfit for interview, those unable to provide informed consent, those for whom English is not their first language, those participating in other research at the Royal Infirmary of Edinburgh, and those who present to the emergency department but who are subsequently discharged without hospital admission N = 518: 259 in each arm of the trial |
| Interventions | Individuals randomised to the experimental group will receive TAU in addition to completing the Volitional Help Sheet with the assistance of a research assistant. A carbon copy of this sheet will also be produced so that participants can take home a copy of the Volitional Help Sheet to refer to as necessary. Approximately 2 months post‐baseline, individuals randomised to the experimental group will receive a similar "booster" help sheet and a covering letter explaining that the Volitional Help Sheet can be completed again if required. |
| Outcomes | Primary outcomes: repetition of self‐harm necessitating hospital admission to any hospital in Scotland during the 6‐month follow‐up period, number of re‐presentations to hospital for self‐harm during the 6‐month follow‐up period, and cost‐effectiveness of the Volitional Help Sheet, as measured by the estimated incremental cost per episode of self‐harm or suicide averted Secondary outcomes: Time to re‐presentation to any hospital in Scotland with self‐harm during the 6‐month follow‐up period measured in weeks, months, or both |
| Starting date | April, 2012. Proposed End Date: April, 2015. |
| Contact information | Name: Prof. Rory O'Connor (PI).Affiliation: The University of Glasgow.Email:[email protected] |
| Notes | Prof Rory O'Connor very kindly provided unpublished information relating to this trial. Additionally, Prof O'Connor provided the following to describe the theoretical basis, content, and purpose of the Volitional Help Sheet: "The intervention takes the form of a help sheet (Armitage 2008), which is developed from three well established theoretical perspectives and previous research: Gollwitzer's concept of Implementation Interventions (Gollwitzer 1993), Prochaska and DiClemente's trans‐theoretical model (Prochaska 1983), Integrated Motivational‐Volitional Model of suicidal behaviour (IMV; O'Connor 2011) and previous work on self‐harm (e.g., O'Connor 2006; O'Connor 2009; Hawton 2006). In essence, the help sheet is a behavioural change technique which encourages participants to link critical situations in which they are tempted to self‐harm with alternative responses/solutions." |
| Study name | Pilot study of a brief intervention for medically hospitalised suicide attempt survivors Trial registration number: NCT02414763. |
| Methods | Allocation: single blind randomisation Design: single centre (hospital‐based), longitudinal design Setting: level 1 trauma centre Location: Nashville, TN, USA |
| Participants | Inclusion criteria: males and females over 17 years of age, who are admitted to a medical or surgical ward following a suicide attempt. Those with psychiatric diagnoses will not be excluded from participation. |
| Interventions | Those randomised to the intervention group will receive a brief intervention of a stepped care protocol, including building rapport, functional analysis of suicidal behavior, and crisis planning for medically admitted suicide attempt survivors in addition to usual care. |
| Outcomes | Primary outcomes: Scores on the Patient Satisfaction Questionnaire, the Readiness to Change, Reasons for Living, Perceived Burdensomeness, Thwarted Belongingness, Acquired Capability, and Scale for Suicidal Ideation scales post‐intervention. In addition, investigators will assess repetition of suicide attempts and non‐suicidal self‐injury post‐intervention. |
| Starting date | Proposed start date: October 2014 Proposed end date: September 2016 |
| Contact information | Name: Prof Stephen O'Connor (Principal investigator) Affiliation: Western Kentucky University email: [email protected] |
| Notes | Prof Stephen O'Connor very kindly provided unpublished information relating to this trial. |
| Study name | Effectiveness of a 24 hour phone line on the rate of suicide attempts in borderline patients. Trial registration number: NCT00603421. |
| Methods | Allocation: single blind, parallel assignment, randomisation Design: multicentre. Setting: in‐ and outpatient clinics Location: various locations around Paris, France Follow‐up period: 1 year |
| Participants | Inclusion criteria: males and females, aged 18‐40 years, diagnosed with borderline personality disorder, treated as in‐ or outpatients at 1 of the trial recruiting centres (Hôpital St Anne and Hôpital Cichin Centre de Recherche Clinque Paris), and able to provide written informed consent Exclusion criteria: those below 18 or over 40 years of age, those diagnosed with schizophrenia or a severe somatic disorder, those who refuse consent to participate, and those already participating in another intervention trial |
| Interventions | Participants randomised to the intervention arm will receive 1 year of access to a 24 h crisis phone line monitored by a team of psychiatrists with experience treating borderline personality disorder patients in addition to TAU |
| Outcomes | Primary outcome measure: annualised rate of suicide attempts Secondary outcome measure: annualised rate of self injurious behaviour |
| Starting date | February 2009. Estimated end date: September 2014 |
| Contact information | Name: Dr Alexandra Pham‐Scottez Affiliation: Centre Hôspitalier Sainte Anne email: [email protected] |
| Notes | We made 3 attempts to contact Dr Pham‐Scottez to confirm these details; however, we received no response and so were unable to confirm whether all participants either engaged in deliberate self‐harm or made a suicide attempt within 6 months prior to randomisation. We extracted information for this trial from the ClinicalTrials.gov record. |
| Study name | RCT of the Clinical and Cost Effectiveness of Cognitive Behaviour Therapy (CBT) Delivered Remotely Versus Treatment as Usual in Adolescents and Young Adults With Depression Who Repeatedly Self‐harm (eDASH). Trial registration number: NCT02377011. |
| Methods | Allocation: single‐blind randomisation Design: single centre Setting: hospital Location: Chesterfield Royal Hospital NHS Foundation Trust |
| Participants | Inclusion criteria: males and females, aged 16‐30 years; within 96 hours of last self‐harm presentation (self‐harm as defined by NICE criteria); with >2 self‐harm episodes; with high levels of unipolar depressive symptoms (BDI‐2 score of 17 or more). Exclusion criteria: clinical judgement of high level of suicide risk, other risk to self or others requiring other urgent approaches; other severe mental illness; currently receiving structured psychological therapy. N expected:120 |
| Interventions | Problem solving cognitive behaviour therapy (PS CBT) will be delivered remotely by means of telephone or video calling by a cognitive behaviour therapist in addition to their usual care. |
| Outcomes | Primary outcome measure: Beck Depression Inventory ((BDI‐II) at 6 months Secondary outcome measures: Beck Depression Inventory (V2); Patient Health Questionnaire 9 (PHQ‐9); Beck hopelessness scale; Columbia Suicide Severity Rating Scale (CSSRS); social functioning (Work and Social Adjustment Scale (WSAS)); quality of life (EQ‐5D); cost effectiveness (modified version of the CSRI); qualitative interviews. All measured at 12 months. |
| Starting date | January 2014. Estimated end date: December 2017 |
| Contact information | |
| Notes |
| Study name | ALGOS. Trial registration number: NCT01123174. |
| Methods | Allocation: single‐blind randomisation Design: multicentre. Setting: 23 community mental health centres Follow‐up period: 6 and 14 months Location: various locations around France |
| Participants | Inclusion criteria: males and females, over 18 years of age, who present to emergency departments following an episode of attempted suicide Exclusion criteria: multiple repeaters, those with 4 or more suicide attempts in the preceding 3 years Expected N: 900 |
| Interventions | Using the ALGOS algorithm, a decision tree concerning the type of contact a participant should receive based on his or her number of previous suicide attempts, first‐time attempters randomised to the experimental group will receive a crisis card. Those with 1‐3 previous suicide attempts in the preceding 3 years, on the other hand, will receive telephone contact on the 10th and 21st day following the most recent suicide attempt, and postcard contact for 5 months. |
| Outcomes | Primary outcome: number of participants who subsequently make a suicide attempt during the follow‐up period Secondary outcomes: number of deaths by suicide, scores on the BSSI, psychopathology as assessed by scores on the MINI, number of health care contacts, and a medico‐economic assessment of the costs of ALGOS |
| Starting date | February, 2010. Proposed end date: April, 2014. |
| Contact information | Name: Prof. Guillaume Vaiva (PI). Affiliation: Centre Hospitalier Régional Universitaire de Lille. email:[email protected] |
| Notes | Prof Guillaume Vaiva very kindly provided unpublished information relating to this trial. |
| Study name | Intensified, Inpatient Adaptation of Dialectical Behavior Therapy (DBT) REDBT. Trial registration number: NCT01904227. |
| Methods | Allocation: randomised, open label Design: single centre Setting: inpatient and outpatient (different arms of trial ‐ Jelgersma Treatment Centre, or the outpatient DBT programs of Rivierduinen) Location: Netherlands |
| Participants | Inclusion criteria: males and females, aged 18 to 40 years, with severe borderline personality disorder( > 24 on the BPDSI), admitted to hospital with suicidal and/or self‐harming behavior in the year preceding the start of DBT treatment, including the last month preceding baseline measurement. Exclusion criteria: IQ < 80; a chronic psychotic condition; bipolar disorder; hard drug abuse that requires inpatient detoxification; forced treatment framework; DBT in the year preceding intake. Expected N: 150 |
| Interventions | Inpatient DBT v outpatient DBT |
| Outcomes | Primary outcome: change in number of suicide attempts/self‐harming acts. Secondary outcomes: change in severity of borderline symptomatology (BPDSI). |
| Starting date | February 2012 Proposed end date: April 2015 (no longer recruiting) |
| Contact information | Name: Louisa M van den Bosch Affiliations: Rivierduinen, Centre for Personality disorders Jelgersma Email: n/a |
| Notes |
| Study name | Women Offenders Repeat Self‐Harm Intervention Pilot II. Trial registration number: ISRCTN18761534. |
| Methods | Allocation: randomisation by minimisation Design: multicentre (3 closed‐category prisons) Setting: closed‐category prisons housing a mixture of remand and sentenced prisoners Follow‐up period: 3 and 6 months Location: Cheshire, Derby, and Yorkshire, UK |
| Participants | Inclusion criteria: female prisoners, 18 years or older, remanded or sentenced to any 1 of 3 prisons for any offence, who have a history of repeated self‐harming behaviour with at least 1 incident within the month prior to randomisation, and are currently on an Assessment, Care in Custody and Teamwork (ACCT). As the trial does not discriminate between the severity and frequency of self‐harming behaviour, previous self‐harming behaviour can range from superficial cuts to ligaturing. Expected N: 120 |
| Interventions | Participants randomised to the experimental group will receive weekly sessions of psychodynamic interpersonal therapy for a minimum of 6 weeks. Those randomised to the control group will receive active control comprising a weekly session of time out of their cell to play card games, read magazines, listen to music, or to discuss practical topics (e.g., developing financial management skills) with research assistants. Women randomised to this group are specifically instructed that they cannot discuss emotive topics with research assistants. |
| Outcomes | Primary outcome: scores on Beck's Scale for Suicidal Ideation immediately post‐treatment (3 months) and at 6 months Secondary outcomes: scores on Beck's Depression Inventory and Beck's Hopelessness Inventory immediately post‐treatment (3 months) and at 6 months. Additionally, information on both the frequency and severity of self‐harm and thoughts of self‐harm immediately post‐treatment (3 months) and at 6 months will be measured using the Self Harm Incidents Questionnaire. Lastly, information on satisfaction with treatment will be assessed immediately post‐treatment (3 months) using the Intervention Satisfaction Questionnaire. |
| Starting date | June, 2013. Proposed end date: June, 2015. |
| Contact information | Name: Dr. Tammi Walker. Affiliations: Institute of Brain, Behaviour and Mental Health (University of Manchester) and School of Social and International Studies (University of Bradford). |
| Notes | Dr Tammi Walker very kindly provided information relating to this trial. |
AUDIT: Alcohol Use Disorders Identification Test; BHS: Beck Hopelessness Scale; BSSI: Beck scale for suicidal ideation; DAST: drug abuse screening test; DSM‐IV: Diagnostic and Statistical Manual for Mental Disorders, fourth edition; MACT: manual‐assisted cognitive therapy; SAPAS: Standardised Assessment of Personality: Abbreviated Scale; SCL‐90‐R: Symptom Checklist‐90‐Revised.
Data and analyses
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Repetition of SH at 6 months Show forest plot | 12 | 1317 | Odds Ratio (M‐H, Random, 95% CI) | 0.54 [0.34, 0.85] |
| Analysis 1.1  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 1: Repetition of SH at 6 months | ||||
| 1.1.1 Individual psychotherapy | 11 | 1083 | Odds Ratio (M‐H, Random, 95% CI) | 0.52 [0.36, 0.75] |
| 1.1.2 Group‐based psychotherapy | 1 | 234 | Odds Ratio (M‐H, Random, 95% CI) | 1.35 [0.75, 2.41] |
| 1.2 Repetition of SH at 12 months Show forest plot | 10 | 2232 | Odds Ratio (M‐H, Random, 95% CI) | 0.80 [0.65, 0.98] |
| Analysis 1.2  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 2: Repetition of SH at 12 months | ||||
| 1.2.1 Individual psychotherapy | 9 | 1799 | Odds Ratio (M‐H, Random, 95% CI) | 0.74 [0.59, 0.94] |
| 1.2.2 Group‐based psychotherapy | 1 | 433 | Odds Ratio (M‐H, Random, 95% CI) | 1.04 [0.67, 1.61] |
| 1.3 Repetition of SH at 24 months Show forest plot | 2 | 105 | Odds Ratio (M‐H, Random, 95% CI) | 0.31 [0.14, 0.69] |
| Analysis 1.3  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 3: Repetition of SH at 24 months | ||||
| 1.3.1 Indivdual psychotherapy | 2 | 105 | Odds Ratio (M‐H, Random, 95% CI) | 0.31 [0.14, 0.69] |
| 1.4 Repetition of SH at final follow‐up Show forest plot | 17 | 2665 | Odds Ratio (M‐H, Random, 95% CI) | 0.70 [0.55, 0.88] |
| Analysis 1.4  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 4: Repetition of SH at final follow‐up | ||||
| 1.4.1 Individual psychotherapy | 16 | 2232 | Odds Ratio (M‐H, Random, 95% CI) | 0.66 [0.53, 0.84] |
| 1.4.2 Group‐based psychotherapy | 1 | 433 | Odds Ratio (M‐H, Random, 95% CI) | 1.04 [0.67, 1.61] |
| 1.5 Frequency of SH at final follow‐up Show forest plot | 6 | 594 | Mean Difference (IV, Random, 95% CI) | ‐0.21 [‐0.68, 0.26] |
| Analysis 1.5  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 5: Frequency of SH at final follow‐up | ||||
| 1.5.1 Individual psychotherapy | 5 | 161 | Mean Difference (IV, Random, 95% CI) | ‐0.66 [‐1.71, 0.40] |
| 1.5.2 Group‐based psychotherapy | 1 | 433 | Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.32, 0.20] |
| 1.6 Depression scores at 6 months Show forest plot | 11 | 1668 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.30 [‐0.50, ‐0.10] |
| Analysis 1.6  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 6: Depression scores at 6 months | ||||
| 1.6.1 Individual psychotherapy | 10 | 1434 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.33 [‐0.56, ‐0.11] |
| 1.6.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.13 [‐0.39, 0.13] |
| 1.7 Depression scores at 12 months Show forest plot | 7 | 1130 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.64, ‐0.07] |
| Analysis 1.7  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 7: Depression scores at 12 months | ||||
| 1.7.1 Individual psychotherapy | 7 | 1130 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.64, ‐0.07] |
| 1.8 Depression scores at 24 months Show forest plot | 2 | 225 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.48, 0.05] |
| Analysis 1.8  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 8: Depression scores at 24 months | ||||
| 1.8.1 Individual psychotherapy | 2 | 225 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.48, 0.05] |
| 1.9 Depression scores at final follow‐up Show forest plot | 14 | 1859 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.31 [‐0.48, ‐0.14] |
| Analysis 1.9  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 9: Depression scores at final follow‐up | ||||
| 1.9.1 Individual psychotherapy | 13 | 1625 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.35 [‐0.54, ‐0.16] |
| 1.9.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.13 [‐0.39, 0.13] |
| 1.10 Hopelessness scores at post‐intervention Show forest plot | 3 | 360 | Mean Difference (IV, Random, 95% CI) | ‐1.50 [‐3.62, 0.61] |
| Analysis 1.10  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 10: Hopelessness scores at post‐intervention | ||||
| 1.10.1 Individual psychotherapy | 2 | 47 | Mean Difference (IV, Random, 95% CI) | ‐4.23 [‐8.71, 0.25] |
| 1.10.2 Group‐based psychotherapy | 1 | 313 | Mean Difference (IV, Random, 95% CI) | ‐0.80 [‐2.17, 0.57] |
| 1.11 Hopelessness scores at 6 months Show forest plot | 4 | 968 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.58, ‐0.13] |
| Analysis 1.11  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 11: Hopelessness scores at 6 months | ||||
| 1.11.1 Individual psychotherapy | 3 | 734 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.48 [‐0.63, ‐0.33] |
| 1.11.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.05 [‐0.31, 0.21] |
| 1.12 Hopelessness scores at 12 months Show forest plot | 3 | 539 | Mean Difference (IV, Random, 95% CI) | ‐1.89 [‐2.97, ‐0.81] |
| Analysis 1.12  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 12: Hopelessness scores at 12 months | ||||
| 1.12.1 Individual psychotherapy | 3 | 539 | Mean Difference (IV, Random, 95% CI) | ‐1.89 [‐2.97, ‐0.81] |
| 1.13 Hopelessness scores at final follow‐up Show forest plot | 7 | 1017 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.31 [‐0.51, ‐0.10] |
| Analysis 1.13  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 13: Hopelessness scores at final follow‐up | ||||
| 1.13.1 Individual psychotherapy | 6 | 783 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.38 [‐0.60, ‐0.16] |
| 1.13.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.05 [‐0.31, 0.21] |
| 1.14 Suicidal ideation scores at post‐intervention Show forest plot | 3 | 360 | Mean Difference (IV, Random, 95% CI) | ‐2.52 [‐5.60, 0.56] |
| Analysis 1.14  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 14: Suicidal ideation scores at post‐intervention | ||||
| 1.14.1 Individual psychotherapy | 2 | 47 | Mean Difference (IV, Random, 95% CI) | ‐5.92 [‐11.98, 0.14] |
| 1.14.2 Group‐based psychotherapy | 1 | 313 | Mean Difference (IV, Random, 95% CI) | ‐1.50 [‐3.50, 0.50] |
| 1.15 Suicidal ideation scores at 6 months Show forest plot | 6 | 1011 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.32 [‐0.51, ‐0.13] |
| Analysis 1.15  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 15: Suicidal ideation scores at 6 months | ||||
| 1.15.1 Individual psychotherapy | 5 | 777 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.41 [‐0.55, ‐0.27] |
| 1.15.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.28, 0.24] |
| 1.16 Suicidal ideation scores at final follow‐up Show forest plot | 8 | 1131 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.47, ‐0.09] |
| Analysis 1.16  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 16: Suicidal ideation scores at final follow‐up | ||||
| 1.16.1 Individual psychotherapy | 7 | 818 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.35 [‐0.55, ‐0.15] |
| 1.16.2 Group‐based psychotherapy | 1 | 313 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.24, 0.20] |
| 1.17 Proportion with improved problems at 6 months Show forest plot | 2 | 231 | Odds Ratio (M‐H, Random, 95% CI) | 2.81 [1.50, 5.24] |
| Analysis 1.17  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 17: Proportion with improved problems at 6 months | ||||
| 1.17.1 Individual psychotherapy | 2 | 231 | Odds Ratio (M‐H, Random, 95% CI) | 2.81 [1.50, 5.24] |
| 1.18 Proportion with improved problems at final follow‐up Show forest plot | 2 | 211 | Odds Ratio (M‐H, Random, 95% CI) | 3.03 [0.74, 12.41] |
| Analysis 1.18  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 18: Proportion with improved problems at final follow‐up | ||||
| 1.18.1 Individual psychotherapy | 2 | 211 | Odds Ratio (M‐H, Random, 95% CI) | 3.03 [0.74, 12.41] |
| 1.19 Problem‐solving scores at post‐intervention Show forest plot | 2 | 328 | Std. Mean Difference (IV, Random, 95% CI) | 0.15 [‐0.07, 0.36] |
| Analysis 1.19  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 19: Problem‐solving scores at post‐intervention | ||||
| 1.19.1 Individual psychotherapy | 1 | 15 | Std. Mean Difference (IV, Random, 95% CI) | 0.29 [‐0.79, 1.37] |
| 1.19.2 Group‐based psychotherapy | 1 | 313 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.08, 0.36] |
| 1.20 Problem‐solving scores at 6 months Show forest plot | 4 | 949 | Std. Mean Difference (IV, Random, 95% CI) | 0.33 [0.08, 0.58] |
| Analysis 1.20  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 20: Problem‐solving scores at 6 months | ||||
| 1.20.1 Individual psychotherapy | 3 | 715 | Std. Mean Difference (IV, Random, 95% CI) | 0.45 [0.30, 0.60] |
| 1.20.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | 0.02 [‐0.24, 0.28] |
| 1.21 Problem‐solving scores at final follow‐up Show forest plot | 5 | 958 | Std. Mean Difference (IV, Random, 95% CI) | 0.26 [0.02, 0.50] |
| Analysis 1.21  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 21: Problem‐solving scores at final follow‐up | ||||
| 1.21.1 Individual psychotherapy | 4 | 724 | Std. Mean Difference (IV, Random, 95% CI) | 0.35 [0.04, 0.66] |
| 1.21.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | 0.02 [‐0.24, 0.28] |
| 1.22 Suicide at final follow‐up Show forest plot | 15 | 2354 | Odds Ratio (M‐H, Random, 95% CI) | 0.66 [0.29, 1.51] |
| Analysis 1.22  Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 22: Suicide at final follow‐up | ||||
| 1.22.1 Individual psychotherapy | 14 | 1921 | Odds Ratio (M‐H, Random, 95% CI) | 0.69 [0.29, 1.67] |
| 1.22.2 Group‐based psychotherapy | 1 | 433 | Odds Ratio (M‐H, Random, 95% CI) | 0.47 [0.04, 5.25] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Repetition of SH at post‐intervention Show forest plot | 9 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.1  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at post‐intervention | ||||
| 2.1.1 Group‐based emotion‐regulation psychotherapy vs TAU | 2 | 83 | Odds Ratio (M‐H, Random, 95% CI) | 0.34 [0.13, 0.88] |
| 2.1.2 Mentalisation vs TAU | 1 | 134 | Odds Ratio (M‐H, Random, 95% CI) | 0.35 [0.17, 0.73] |
| 2.1.3 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Odds Ratio (M‐H, Random, 95% CI) | 0.05 [0.00, 0.49] |
| 2.1.4 DBT vs TAU | 3 | 267 | Odds Ratio (M‐H, Random, 95% CI) | 0.59 [0.16, 2.15] |
| 2.1.5 DBT vs treatment by expert | 1 | 97 | Odds Ratio (M‐H, Random, 95% CI) | 1.66 [0.53, 5.20] |
| 2.1.6 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Odds Ratio (M‐H, Random, 95% CI) | 0.67 [0.08, 5.68] |
| 2.2 Repetition of SH at 6 months Show forest plot | 1 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.2  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Repetition of SH at 6 months | ||||
| 2.2.1 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Odds Ratio (M‐H, Random, 95% CI) | 0.67 [0.08, 5.68] |
| 2.3 Repetition of SH at 12 months Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.3  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 3: Repetition of SH at 12 months | ||||
| 2.3.1 DBT vs. TAU | 2 | 172 | Odds Ratio (M‐H, Random, 95% CI) | 0.36 [0.05, 2.47] |
| 2.3.2 DBT vs treatment by expert | 1 | 97 | Odds Ratio (M‐H, Random, 95% CI) | 1.18 [0.35, 3.95] |
| 2.4 Repetition of SH at final follow‐up Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.4  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 4: Repetition of SH at final follow‐up | ||||
| 2.4.1 DBT vs TAU | 3 | 247 | Odds Ratio (M‐H, Random, 95% CI) | 0.57 [0.21, 1.59] |
| 2.5 Frequency of repetition of SH at post‐intervention Show forest plot | 9 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.5  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 5: Frequency of repetition of SH at post‐intervention | ||||
| 2.5.1 Group‐based emotion‐regulation psychotherapy vs TAU | 2 | 83 | Mean Difference (IV, Random, 95% CI) | ‐12.76 [‐34.92, 9.40] |
| 2.5.2 Mentalisaiton vs TAU | 1 | 134 | Mean Difference (IV, Random, 95% CI) | ‐1.28 [‐2.01, ‐0.55] |
| 2.5.3 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Mean Difference (IV, Random, 95% CI) | ‐4.83 [‐7.90, ‐1.76] |
| 2.5.4 DBT vs TAU | 3 | 292 | Mean Difference (IV, Random, 95% CI) | ‐18.82 [‐36.68, ‐0.95] |
| 2.5.5 DBT vs treatment by expert | 1 | 97 | Mean Difference (IV, Random, 95% CI) | ‐14.85 [‐37.64, 7.94] |
| 2.5.6 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | ‐0.25 [‐2.47, 1.97] |
| 2.6 Frequency of repetition of SH at 6 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.6  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 6: Frequency of repetition of SH at 6 months | ||||
| 2.6.1 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | 0.34 [‐0.61, 1.29] |
| 2.7 Number completing full course of treatment Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.7  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 7: Number completing full course of treatment | ||||
| 2.7.1 Mentalisation vs TAU | 1 | 134 | Odds Ratio (M‐H, Random, 95% CI) | 0.93 [0.43, 2.02] |
| 2.7.2 DBT‐oriented therapy vs TAU | 1 | 24 | Odds Ratio (M‐H, Random, 95% CI) | 3.00 [0.53, 16.90] |
| 2.7.3 DBT prolonged exposure vs DBT standard exposure | 1 | 26 | Odds Ratio (M‐H, Random, 95% CI) | 1.14 [0.22, 5.84] |
| 2.8 Depression scores at post‐intervention Show forest plot | 8 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.8  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 8: Depression scores at post‐intervention | ||||
| 2.8.1 Group‐based emotion‐regulation psychotherapy vs TAU | 2 | 83 | Mean Difference (IV, Random, 95% CI) | ‐9.59 [‐13.43, ‐5.75] |
| 2.8.2 Mentalisaiton vs TAU | 1 | 134 | Mean Difference (IV, Random, 95% CI) | ‐3.88 [‐6.82, ‐0.94] |
| 2.8.3 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Mean Difference (IV, Random, 95% CI) | ‐9.16 [‐14.79, ‐3.53] |
| 2.8.4 DBT vs TAU | 2 | 198 | Mean Difference (IV, Random, 95% CI) | ‐2.37 [‐6.52, 1.78] |
| 2.8.5 DBT vs treatment by expert | 1 | 89 | Mean Difference (IV, Random, 95% CI) | ‐3.00 [‐6.27, 0.27] |
| 2.8.6 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | ‐3.70 [‐10.59, 3.19] |
| 2.9 Depression scores at 6 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.9  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 9: Depression scores at 6 months | ||||
| 2.9.1 DBT prolonged exposure vs. DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | ‐4.30 [‐9.68, 1.08] |
| 2.10 Depression scores at 12 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.10  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 10: Depression scores at 12 months | ||||
| 2.10.1 DBT vs treatment by expert | 1 | 81 | Mean Difference (IV, Random, 95% CI) | ‐1.80 [‐5.40, 1.80] |
| 2.11 Suicide ideation scores at post‐intervention Show forest plot | 2 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.11  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 11: Suicide ideation scores at post‐intervention | ||||
| 2.11.1 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Mean Difference (IV, Random, 95% CI) | ‐7.75 [‐14.66, ‐0.84] |
| 2.11.2 DBT vs treatment by expert | 1 | 89 | Mean Difference (IV, Random, 95% CI) | ‐3.00 [‐13.69, 7.69] |
| 2.12 Suicide ideation scores at 12 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 2.12  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 12: Suicide ideation scores at 12 months | ||||
| 2.12.1 DBT vs treatment by expert | 1 | 81 | Mean Difference (IV, Random, 95% CI) | ‐7.82 [‐18.38, 2.74] |
| 2.13 Suicide at post‐intervention Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.13  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 13: Suicide at post‐intervention | ||||
| 2.13.1 DBT vs TAU | 3 | 317 | Odds Ratio (M‐H, Random, 95% CI) | 3.00 [0.12, 76.49] |
| 2.14 Suicide at 6 months Show forest plot | 1 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 2.14  Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 14: Suicide at 6 months | ||||
| 2.14.1 DBT prolonged exposure vs DBT standard exposure | 1 | 26 | Odds Ratio (M‐H, Random, 95% CI) | 0.16 [0.01, 4.41] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Repetition of SH at post‐intervention Show forest plot | 4 | 1608 | Odds Ratio (M‐H, Random, 95% CI) | 0.78 [0.47, 1.30] |
| Analysis 3.1  Comparison 3: Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at post‐intervention | ||||
| 3.1.1 Case management plus assertive outreach vs TAU | 3 | 843 | Odds Ratio (M‐H, Random, 95% CI) | 0.82 [0.38, 1.78] |
| 3.1.2 Case management plus assertive outreach vs enhanced usual care | 1 | 765 | Odds Ratio (M‐H, Random, 95% CI) | 0.67 [0.40, 1.10] |
| 3.2 Suicide at post‐intervention Show forest plot | 4 | 1757 | Odds Ratio (M‐H, Random, 95% CI) | 0.95 [0.57, 1.57] |
| Analysis 3.2  Comparison 3: Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Suicide at post‐intervention | ||||
| 3.2.1 Case management plus assertive outreach vs TAU | 3 | 843 | Odds Ratio (M‐H, Random, 95% CI) | 1.77 [0.36, 8.68] |
| 3.2.2 Case management plus assertive outreach vs enhanced usual care | 1 | 914 | Odds Ratio (M‐H, Random, 95% CI) | 0.88 [0.52, 1.51] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Repetition of SH at 12 months Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 4.1  Comparison 4: Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at 12 months | ||||
| 4.1.1 Adherence enhancement vs TAU | 1 | 391 | Odds Ratio (M‐H, Random, 95% CI) | 0.57 [0.32, 1.02] |
| 4.1.2 Continuity of care by the same therapist vs other alternative forms of psychotherapy | 1 | 136 | Odds Ratio (M‐H, Random, 95% CI) | 0.28 [0.07, 1.10] |
| 4.2 Depression scores at 12 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 4.2  Comparison 4: Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Depression scores at 12 months | ||||
| 4.2.1 Continuity of care by the same therapist vs other alternative forms of psychotherapy | 1 | 127 | Mean Difference (IV, Random, 95% CI) | ‐1.40 [‐4.24, 1.44] |
| 4.3 Suicide at 12 months Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 4.3  Comparison 4: Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 3: Suicide at 12 months | ||||
| 4.3.1 Adherence enhancement vs TAU | 1 | 391 | Odds Ratio (M‐H, Random, 95% CI) | 0.85 [0.28, 2.57] |
| 4.3.2 Continuity of care by the same therapist vs other alternative forms of psychotherapy | 1 | 136 | Odds Ratio (M‐H, Random, 95% CI) | 0.62 [0.10, 3.82] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 5.1 Repetition of SH at post‐intervention Show forest plot | 8 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 5.1  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 1: Repetition of SH at post‐intervention | ||||
| 5.1.1 Postcards vs TAU | 4 | 3277 | Odds Ratio (M‐H, Random, 95% CI) | 0.87 [0.62, 1.23] |
| 5.1.2 Emergency cards vs TAU | 2 | 1039 | Odds Ratio (M‐H, Random, 95% CI) | 0.82 [0.31, 2.14] |
| 5.1.3 GP letter vs TAU | 1 | 1932 | Odds Ratio (M‐H, Random, 95% CI) | 1.15 [0.93, 1.44] |
| 5.1.4 Mobile telephone‐based psychotherapy vs TAU | 1 | 68 | Odds Ratio (M‐H, Random, 95% CI) | Not estimable |
| 5.2 Repetition of SH at 12 months Show forest plot | 4 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 5.2  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 2: Repetition of SH at 12 months | ||||
| 5.2.1 Postcards vs TAU | 2 | 2885 | Odds Ratio (M‐H, Random, 95% CI) | 0.76 [0.57, 1.02] |
| 5.2.2 Emergency cards vs TAU | 1 | 827 | Odds Ratio (M‐H, Random, 95% CI) | 1.19 [0.85, 1.67] |
| 5.2.3 Telephone contact vs TAU | 1 | 172 | Odds Ratio (M‐H, Random, 95% CI) | 1.00 [0.45, 2.23] |
| 5.3 Repetition of SH at final follow‐up Show forest plot | 7 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 5.3  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 3: Repetition of SH at final follow‐up | ||||
| 5.3.1 Postcards vs TAU | 4 | 3277 | Odds Ratio (M‐H, Random, 95% CI) | 0.88 [0.62, 1.25] |
| 5.3.2 Telephone contact vs TAU | 3 | 840 | Odds Ratio (M‐H, Random, 95% CI) | 0.74 [0.42, 1.32] |
| 5.4 Frequency of SH at post‐intervention Show forest plot | 3 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 5.4  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 4: Frequency of SH at post‐intervention | ||||
| 5.4.1 Postcards vs TAU | 3 | 1097 | Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.32, 0.18] |
| 5.4.2 Postcards vs TAU (males only) | 3 | 401 | Mean Difference (IV, Random, 95% CI) | ‐0.00 [‐0.13, 0.12] |
| 5.4.3 Postcards vs TAU (females only) | 3 | 695 | Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.29, 0.20] |
| 5.4.4 Postcards vs TAU (history of prior SH) | 3 | 339 | Mean Difference (IV, Random, 95% CI) | ‐0.09 [‐0.68, 0.51] |
| 5.4.5 Postcards vs TAU (no history of prior SH) | 3 | 758 | Mean Difference (IV, Random, 95% CI) | 0.23 [‐0.32, 0.77] |
| 5.5 Frequency of SH at 12 months Show forest plot | 2 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| Analysis 5.5  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 5: Frequency of SH at 12 months | ||||
| 5.5.1 Postcards vs TAU | 2 | 984 | Mean Difference (IV, Random, 95% CI) | ‐0.19 [‐0.58, 0.20] |
| 5.5.2 Postcards vs TAU (males only) | 2 | 336 | Mean Difference (IV, Random, 95% CI) | 0.03 [‐0.11, 0.16] |
| 5.5.3 Postcards vs TAU (females only) | 2 | 647 | Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.62, 0.18] |
| 5.5.4 Postcards vs TAU (history of prior SH) | 2 | 296 | Mean Difference (IV, Random, 95% CI) | ‐0.64 [‐2.07, 0.80] |
| 5.5.5 Postcards vs TAU (no history of prior SH) | 2 | 688 | Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.22, 0.09] |
| 5.6 Suicide at post‐intervention Show forest plot | 5 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 5.6  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 6: Suicide at post‐intervention | ||||
| 5.6.1 Postcards vs TAU | 4 | 3464 | Odds Ratio (M‐H, Random, 95% CI) | 1.86 [0.61, 5.72] |
| 5.6.2 Mobile telephone‐based psychotherapy vs TAU | 1 | 68 | Odds Ratio (M‐H, Random, 95% CI) | 3.09 [0.12, 78.55] |
| 5.7 Suicide at 12 months Show forest plot | 1 | 772 | Odds Ratio (M‐H, Random, 95% CI) | 0.41 [0.08, 2.15] |
| Analysis 5.7  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 7: Suicide at 12 months | ||||
| 5.7.1 Postcards vs TAU | 1 | 772 | Odds Ratio (M‐H, Random, 95% CI) | 0.41 [0.08, 2.15] |
| 5.8 Suicide at final follow‐up Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 5.8  Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 8: Suicide at final follow‐up | ||||
| 5.8.1 Telephone contact vs TAU | 2 | 821 | Odds Ratio (M‐H, Random, 95% CI) | 0.70 [0.11, 4.33] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 6.1 Repetition of SH at final follow‐up Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 6.1  Comparison 6: Other mixed interventions versus treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at final follow‐up | ||||
| 6.1.1 Intensive outpatient intervention vs TAU | 2 | 245 | Odds Ratio (M‐H, Random, 95% CI) | 0.65 [0.15, 2.85] |
Search flow diagram of included and excluded studies for the 2014 update.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Funnel plot of comparison 1: CBT‐based psychotherapy vs treatment as usual for repetition of SH at six months
Funnel plot of comparison 1: CBT‐based psychotherapy vs treatment as usual for repetition of SH at 12 months
Funnel plot of comparison 1: CBT‐based psychotherapy vs treatment as usual for repetition of SH at final follow‐up
Funnel plot of comparison 1: CBT‐based psychotherapy vs Treatment as usual for depression scores at final follow‐up.
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 1: Repetition of SH at 6 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 2: Repetition of SH at 12 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 3: Repetition of SH at 24 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 4: Repetition of SH at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 5: Frequency of SH at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 6: Depression scores at 6 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 7: Depression scores at 12 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 8: Depression scores at 24 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 9: Depression scores at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 10: Hopelessness scores at post‐intervention
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 11: Hopelessness scores at 6 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 12: Hopelessness scores at 12 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 13: Hopelessness scores at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 14: Suicidal ideation scores at post‐intervention
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 15: Suicidal ideation scores at 6 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 16: Suicidal ideation scores at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 17: Proportion with improved problems at 6 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 18: Proportion with improved problems at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 19: Problem‐solving scores at post‐intervention
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 20: Problem‐solving scores at 6 months
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 21: Problem‐solving scores at final follow‐up
Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 22: Suicide at final follow‐up
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at post‐intervention
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Repetition of SH at 6 months
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 3: Repetition of SH at 12 months
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 4: Repetition of SH at final follow‐up
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 5: Frequency of repetition of SH at post‐intervention
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 6: Frequency of repetition of SH at 6 months
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 7: Number completing full course of treatment
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 8: Depression scores at post‐intervention
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 9: Depression scores at 6 months
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 10: Depression scores at 12 months
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 11: Suicide ideation scores at post‐intervention
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 12: Suicide ideation scores at 12 months
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 13: Suicide at post‐intervention
Comparison 2: Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 14: Suicide at 6 months
Comparison 3: Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at post‐intervention
Comparison 3: Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Suicide at post‐intervention
Comparison 4: Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at 12 months
Comparison 4: Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Depression scores at 12 months
Comparison 4: Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 3: Suicide at 12 months
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 1: Repetition of SH at post‐intervention
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 2: Repetition of SH at 12 months
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 3: Repetition of SH at final follow‐up
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 4: Frequency of SH at post‐intervention
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 5: Frequency of SH at 12 months
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 6: Suicide at post‐intervention
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 7: Suicide at 12 months
Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 8: Suicide at final follow‐up
Comparison 6: Other mixed interventions versus treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 1: Repetition of SH at final follow‐up
| CBT‐based psychotherapy vs treatment as usual for self‐harm in adults | ||||||
| Patient or population: adults who engage in SH | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| TAU | CBT‐based psychotherapy | |||||
| Repetition of SH at post‐intervention | Study population | OR 0.66 | 313 | ⊕⊕⊝⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 190 per 1000 | 134 per 1000 | |||||
| Repetition of SH at 6 months | Study population | OR 0.54 | 1317 | ⊕⊕⊕⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. For some trials, additionally, participants were also not blinded to treatment allocation. | |
| 280 per 1000 | 173 per 1000 | |||||
| Repetition of SH at 12 months | Study population | OR 0.80 | 2232 | ⊕⊕⊕⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. For some trials, additionally, participants were also not blinded to treatment allocation. | |
| 272 per 1000 | 230 per 1000 | |||||
| Repetition of SH at 24 months | Study population | OR 0.31 | 105 | ⊕⊕⊕⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. For 1 trial, additionally, participants were also not blinded to treatment allocation. | |
| 563 per 1000 | 285 per 1000 | |||||
| Repetition of SH at final follow‐up | Study population | OR 0.70 | 2665 | ⊕⊕⊝⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. For 1 trial, additionally, participants were also not blinded to treatment allocation. We further downgraded quality due to the inconsistency in the magnitude of the effect size estimates across trials. | |
| 262 per 1000 | 199 per 1000 | |||||
| Frequency of SH at final follow‐up | The mean frequency of episodes of SH in the experimental group was, on average, 0.21 lower (0.68 lower to 0.26 higher) | ‐ | 597 | ⊕⊕⊝⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. For 1 trial, additionally, participants were also not blinded to treatment allocation. We further downgraded quality due to the inconsistency in the magnitude of the effect size estimates across trials. | |
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| a We rated risk of bias as SERIOUS as the nature of the intervention means that clinical personnel could not have remained blind to treatment allocation. Additionally, for some trials, participants were not blinded to treatment allocation. Performance and detection bias therefore may have been present. b Imprecision was rated as SERIOUS as the confidence interval is wide | ||||||
| Interventions for multiple repetition of SH/probable personality disorder vs treatment as usual or other alternative forms of psychotherapy | |||||||
| Patient or population: adults who engage in SH | |||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | ||
|---|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | ||||||
| TAU/other alternative forms of psychotherapy | Interventions for multiple repetition of SH/probable personality disorder | ||||||
| Emotion‐regulation group‐based psychotherapy vs TAU | |||||||
| Repetition of SH at post‐intervention | Study population | OR 0.34 | 83 | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. Additionally, for 1 trial, outcome assessors were also not blind to treatment allocation. We further downgraded quality as study investigators did not adequately describe details on sequence generation and allocation concealment. | ||
| 775 per 1000 | 539 per 1000 | ||||||
| Frequency of SH at post‐intervention | Study population | — | 83 | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. Study investigators also did not adequately describe details on sequence generation and allocation concealment. Additionally, for 1 trial, outcome assessors were also not blind to treatment allocation As the confidence interval for the treatment effect size is wide, we further downgraded quality due to imprecision. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,12.76 lower (34.92 lower to 9.40 higher) | |||||||
| Mentalisation vs TAU | |||||||
| Repetition of SH at post‐intervention | Study population | OR 0.35 | 134 | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. | ||
| 492 per 1000 | 253 per 1000 | ||||||
| Frequency of SH at post‐intervention | Study population | — | 133 | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. Additionally, as the confidence interval for the treatment effect size is wide, we further downgraded quality. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,1.28 lower (2.01 lower to 0.55 lower) | |||||||
| DBT‐oriented therapy vs Alternative forms of psychotherapy | |||||||
| Repetition of SH at post‐intervention | Study population | OR 0.05 (0.00 to 0.49) | 24 | ⊕⊕⊝⊝ Lowb,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the sample size is small. | ||
| 667 per 1000 | 91 per 1000 | ||||||
| Frequency of SH at post‐intervention | Study population | — | 24 | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the sample size is small. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,4.83 lower (7.90 lower to 1.76 lower) | |||||||
| DBT vs TAU | |||||||
| Repetition of SH at post‐intervention | Study population | OR 0.59 (0.16 to 2.15) | 267 | ⊕⊕⊝⊝ Lowb,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to notable differences in the magnitude of the effect size estimates between trials on visual inspection of the forest plot. | ||
| 667 per 1000 | 541 per 1000 | ||||||
| Repetition of SH at 12 months' follow‐up | Study population | OR 0.36 (0.05 to 2.47) | 172 | ⊕⊕⊝⊝ Lowb,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to notable differences in the magnitude of the effect size estimates between trials on visual inspection of the forest plot. | ||
| 495 per 1000 | 260 per 1000 | ||||||
| Repetition of SH at final follow‐up | Study population | OR 0.57 (0.21 to 1.59) | 247 | ⊕⊕⊝⊝ Lowb,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to notable differences in the magnitude of the effect size estimates between trials on visual inspection of the forest plot. | ||
| 620 per 1000 | 482 per 1000 | ||||||
| Frequency of SH at post‐intervention | Study population | — | 292 | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to imprecision of the effect size estimate. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,18.82 lower (36.68 lower to 0.95 lower) | |||||||
| DBT vs treatment by expert | |||||||
| Repetition of SH at post‐intervention | Study population | OR 1.66 (0.53 to 5.20) | 97 | ⊕⊝⊝⊝ Very lowa,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. Additionally, study authors did not adequately describe details on allocation concealment. Lastly, as the confidence interval for the treatment effect size is wide, we further downgraded quality. | ||
| 822 per 1000 | 885 per 1000 | ||||||
| Repetition of SH at 12 months | Study population | OR 1.18 (0.35 to 3.95) | 97 | ⊕⊝⊝⊝ Very lowa,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. Study authors did not adequately describe details on allocation concealment. Lastly, as the confidence interval for the treatment effect size is wide, we further downgraded quality. | ||
| 867 per 1000 | 885 per 1000 | ||||||
| Frequency of SH at post‐intervention | Study population | — | 97 | ⊕⊝⊝⊝ Very lowa,c | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. Study authors did not adequately describe details on allocation concealment. Lastly, as the confidence interval for the treatment effect size is wide, we further downgraded quality. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,14.85 lower (37.64 lower to 7.94 higher) | |||||||
| DBT prolonged exposure vs DBT standard exposure | |||||||
| Repetition of SH at post‐intervention | Study population | OR 0.67 (0.08 to 5.68) | 18 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as details on participant and clinical personnel blinding were not adequately described. However, given the similarity between the intervention and control treatment in this trial, it is possible that blinding could have been achieved. We further downgraded quality as the confidence interval for the treatment effect size is wide. | ||
| 333 per 1000 | 251 per 1000 (38 to 740) | ||||||
| Repetition of SH at 6 months' follow‐up | Study population | OR 0.67 (0.08 to 5.68) | 18 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as details on participant and clinical personnel blinding were not adequately described. However, given the similarity between the intervention and control treatment in this trial, it is possible that blinding could have been achieved. We further downgraded quality as the confidence interval for the treatment effect size is wide. | ||
| 333 per 1000 | 251 per 1000 (38 to 740) | ||||||
| Frequency of SH at post‐intervention | Study population | — | 18 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as details on participant and clinical personnel blinding were not adequately described. However, given the similarity between the intervention and control treatment in this trial, it is possible that blinding could have been achieved. We further downgraded quality as the confidence interval for the treatment effect size is wide. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,0.25 lower (2.47 lower to 1.97 higher) | |||||||
| Frequency of SH at 6 months' follow‐up | Study population | — | 18 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as details on participant and clinical personnel blinding were not adequately described. However, given the similarity between the intervention and control treatment in this trial, it is possible that blinding could have been achieved. We further downgraded quality as the confidence interval for the treatment effect size is wide. | ||
| The mean frequency of episodes of SH in the experimental group was, on average,0.34 higher (0.61 lower to 1.29 higher) | |||||||
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | |||||||
| GRADE Working Group grades of evidence | |||||||
| a Risk of bias was rated as VERY SERIOUS as the nature of the intervention means that participants and clinical personnel could not have remained blind to treatment allocation, suggesting that performance and detection bias may have been present. For 1 trial, outcome assessors were not blind to treatment allocation. Additionally, as details on sequence generation and allocation concealment were not adequately described, selection bias may have been present. | |||||||
| Case management vs treatment as usual or other alternative forms of psychotherapy | ||||||
| Patient or population: adults who engage in SH Comparison: treatment as usual (TAU) or other alternative forms of psychotherapy. | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| TAU/other alternative forms of psychotherapy | Case management | |||||
| Repetition of SH at post‐intervention | Study population | OR 0.78 (0.47 to 1.30) | 1608 (4 RCTs) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. | |
| 114 per 1000 | 91 per 1000 (57 to 143) | |||||
| Multiple readmissions for SH at post‐intervention | Study population | OR 5.23 (1.12 to 24.45) | 469 (1 RCT) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. | |
| 8 per 1000 | 41 per 1000 (9 to 166) | |||||
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| a Risk of bias was rated as SERIOUS as the nature of the intervention means that participants and clinical personnel could not have remained blind to treatment allocation. | ||||||
| Adherence enhancement approaches vs treatment as usual or other alternative forms of psychotherapy | ||||||
| Patient or population: adults who engage in SH Intervention: Adherence enhancement approaches | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| TAU/other alternative forms of psychotherapy | Adherence enhancement approaches | |||||
| Compliance enhancement vs TAU | ||||||
| Repetition of SH at 12 months' follow‐up | Study population | OR 0.57 | 391 | ⊕⊕⊝⊝ | We downgraded quality as an open random numbers table was used to generate the allocation sequence and, as allocation was not concealed, there is possible selection bias. We further downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. | |
| 174 per 1000 | 107 per 1000 | |||||
| Continuity of care by the same therapist vs other alternative forms of psychotherapy (i.e., care by a different therapist) | ||||||
| Repetition of SH at 12 months' follow‐up | Study population | OR 0.28 (0.07 to 1.10) | 136 (1 RCT) | ⊕⊝⊝⊝ | We downgraded quality as neither participants, clinical personnel, nor outcome assessors were blind to treatment allocation. We further downgraded quality as study authors did not specify the method used to allocate participants to the experimental and control groups, nor did they report details on allocation concealment. Finally, we downgraded quality three grades, as there was significant imbalance between the experimental and control group for some putative risk factors for repetition of SH despite randomisation. | |
| 136 per 1000 | 42 per 1000 (11 to 148) | |||||
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| a Risk of bias was rated as VERY SERIOUS as the nature of the intervention means that participants and clinical personnel could not have remained blind to treatment allocation, suggesting that performance and detection bias may have been present. As an open numbers table was used the generate the allocation sequence, and as allocation was not concealed, selection bias also may have been present. | ||||||
| Mixed multimodal interventions vs treatment as usual | ||||||
| Patient or population: adults who engage in SH | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| TAU | Mixed multimodal Interventions | |||||
| Mixed multimodal interventions vs TAU | ||||||
| Repetition of SH at post‐intervention | Study population | OR 0.98 | 684 | ⊕⊕⊝⊝ | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. Additionally, use of Zelen's post‐consent design would indicate that participants were also not blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 204 per 1000 | 201 per 1000 | |||||
| Culturally‐adapted mixed multimodal interventions vs TAU | ||||||
| Repetition of SH at 12 months | Study population | OR 0.83 (0.44 to 1.55) | 167 (1 RCT) | ⊕⊕⊝⊝ Lowa,b | We downgraded quality as, due to the nature of the intervention, it is unlikely participants and clinical personnel would have been blind to treatment allocation. Additionally, use of Zelen's post‐consent design would indicate that participants were also not blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 403 per 1000 | 359 per 1000 (229 to 511) | |||||
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| a Risk of bias was rated as SERIOUS, as the nature of the intervention means that participants and clinical personnel could not have remained blind to treatment allocation. Additionally, the use of Zelen's post‐consent design indicates that participants would not have been blind to treatment allocation. Performance and detection bias therefore may have been present. b Imprecision was rated as SERIOUS as the confidence interval is wide. | ||||||
| Remote contact interventions vs treatment as usual | ||||||
| Patient or population: adults who engage in SH | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| TAU | Remote contact interventions | |||||
| Postcards vs TAU | ||||||
| Repetition of SH at post‐intervention | Study population | OR 0.87 | 3277 | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to significant differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| 132 per 1000 | 117 per 1000 | |||||
| Repetition of SH at 12 months | Study population | OR 0.76 | 2885 | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. | |
| 175 per 1000 | 139 per 1000 | |||||
| Repetition of SH at final follow‐up | Study population | OR 0.88 | 3277 | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to significant differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| 185 per 1000 | 167 per 1000 | |||||
| Frequency of SH at post‐intervention | Study population | — | 1097 (3 RCTs) | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to significant differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| The mean frequency of episodes of | ||||||
| Frequency of SH at 12 months | Study population | — | 984 (2 RCTs) | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to significant differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| The mean frequency of episodes of | ||||||
| Frequency of SH at 24 months | Study population | — | 472 (1 RCT) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. | |
| The mean frequency of episodes of | ||||||
| Emergency cards vs TAU | ||||||
| Repetition of SH at post‐intervention | Study population | OR 0.82 (0.31 to 2.14) | 1039 (2 RCTs) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel were bind to treatment allocation. Additionally, quality was further downgraded due to notable differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| 171 per 1000 | 145 per 1000 (60 to 306) | |||||
| Repetition of SH at 12 months' follow‐up | Study population | OR 1.19 (0.85 to 1.67) | 827 (1 RCT) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel were bind to treatment allocation. | |
| 188 per 1000 | 216 per 1000 (164 to 279) | |||||
| General practitioner's (GP) letter vsTAU | ||||||
| Repetition of SH at post‐intervention | Study population | OR 1.15 (0.93 to 1.44) | 1932 (1 RCT) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. | |
| 195 per 1000 | 218 per 1000 (184 to 259) | |||||
| Telephone contact vs TAU | ||||||
| Repetition of SH at 6 months' follow‐up | Study population | OR 0.23 (0.02 to 2.11) | 81 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 100 per 1000 | 25 per 1000 (2 to 190) | |||||
| Repetition of SH at 12 months' follow‐up | Study population | OR 1.00 (0.45 to 2.23) | 172 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 169 per 1000 | 169 per 1000 (84 to 311) | |||||
| Repetition of SH at 24 months' follow‐up | Study population | OR 0.76 (0.49 to 1.16) | 605 (1 RCT) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 189 per 1000 | 151 per 1000 (103 to 213) | |||||
| Repetition of SH at final follow‐up | Study population | OR 0.74 (0.42 to 1.32) | 840 (3 RCTs) | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality due to significant differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| 185 per 1000 | 143 per 1000 (87 to 230) | |||||
| Mobile telephone‐based psychotherapy vs TAU | ||||||
| Repetition of SH at post‐intervention | Study population | Not estimable | 68 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely that participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as the sample size is small. | |
| 0 per 1000 | 0 per 1000 (0 to 0) | |||||
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| a Risk of bias was rated as SERIOUS as the nature of the intervention means that participants and clinical personnel could not have remained blind to treatment allocation. Additionally, for some trials, no details on outcome assessor blinding were reported. Performance and detection bias therefore may have been present. e Imprecision was rated as SERIOUS as the confidence interval is wide and/or the sample size is small. | ||||||
| Heterogeneous other interventions vs treatment as usual or other alternative forms of psychotherapy | ||||||
| Patient or population: adults who engage in SH Settings: mixture of in‐ and outpatients Intervention: other mixed interventions | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Assumed risk | Corresponding risk | |||||
| TAU or other alternative forms of psychotherapy | Heterogenous other interventions | |||||
| Interpersonal problem‐solving skills training vs other alternative forms of psychotherapy | ||||||
| Repetition of SH at 12 months | Study population | OR 0.40 (0.06 to 2.57) | 33 (1 RCT) | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation. We further downgraded quality as an open random numbers table was used to generate the allocation sequence and, as allocation was not concealed, there is possible selection bias. We further downgraded quality as the sample size is small. | |
| 250 per 1000 | 118 per 1000 (20 to 461) | |||||
| Behaviour therapy vs other alternative forms of psychotherapy | ||||||
| Repetition of SH at 12 months | Study population | OR 0.60 (0.08 to 4.45) | 24 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as clinical personnel were not blind to treatment allocation. Additionally, details on sequence generation, allocation concealment, participant blinding, and outcome assessor blinding were not adequately described. Lastly, as the confidence interval for the treatment effect size is wide, we further downgraded quality. | |
| 250 per 1000 | 167 per 1000 (26 to 597) | |||||
| Information and support vs TAU | ||||||
| Repetition of SH at final follow‐up for the overall cohort | Study population | OR 1.02 | 1663 | ⊕⊕⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. | |
| 75 per 1000 | 76 per 1000 | |||||
| Repetition of SH at final follow‐up for the Campinas, Brazil site | Study population | OR 2.27 | 135 | ⊕⊝⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. We downgraded quality three grades for this site as the confidence interval for the treatment effect size is wide. | |
| 156 per 1000 | 296 per 1000 | |||||
| Repetition of SH at final follow‐up for the Colombo, Sri Lanka site | Study population | OR 0.55 | 251 | ⊕⊝⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. We further downgraded quality for this site as the confidence interval for the treatment effect size is wide. | |
| 41 per 1000 | 23 per 1000 | |||||
| Repetition of SH at final follow‐up for the Karaj, Iran site | Study population | OR 1.18 | 601 | ⊕⊕⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. | |
| 94 per 1000 | 109 per 1000 | |||||
| Repetition of SH at final follow‐up for the Yuncheng, China site | Study population | OR 2.01 | 96 | ⊕⊝⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. We further downgraded quality for this site as the confidence interval for the treatment effect size is wide. | |
| 0 per 1000 | 0 per 1000 | |||||
| Repetition of SH at final follow‐up for the Chennai, India site | Study population | OR 0.39 | 561 | ⊕⊕⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. | |
| 65 per 1000 | 27 per 1000 | |||||
| Frequency of SH at final follow‐up for the Karaj, Iran site | The frequency of episodes of SH for the Karaj, Iran site in the experimental group was, on average, 0.46 higher (0.32 higher to 0.32 higher) | — | 629 | ⊕⊕⊝⊝ | We downgraded quality as the nature of the intervention means it is unlikely that clinical personnel would have been blind to treatment allocation. We further downgraded quality as attrition bias may have been present. | |
| Treatment for alcohol misuse vs TAU | ||||||
| Repetition of SH at 6 months | Study population | OR 0.57 (0.20 to 1.60) | 103 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 216 per 1000 | 136 per 1000 (52 to 306) | |||||
| Home‐based problem‐solving therapy vs other alternative forms of psychotherapy | ||||||
| Repetition of SH at 12 months | Study population | OR 0.68 (0.20 to 2.32) | 96 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 146 per 1000 | 104 per 1000 (33 to 284) | |||||
| Intensive inpatient and community treatment vs TAU | ||||||
| Repetition of SH at 12 months | Study population | OR 1.18 (0.62 to 2.25) | 274 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. We further downgraded quality as the confidence interval for the treatment effect size is wide. | |
| 149 per 1000 | 172 per 1000 (98 to 283) | |||||
| Frequency of SH at 12 months | Study population | — | 274 (1 RCT) | ⊕⊕⊕⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. | |
| The mean frequency of | The mean frequency of SH at 12 months in the experimental group was 0 higher (0.17 lower to 0.17 higher | |||||
| General hospital admission vs other alternative forms of psychotherapy | ||||||
| Repetition of SH at post‐intervention | Study population | OR 1.03 (0.14 to 7.69) | 77 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. Lastly, as the confidence interval for the treatment effect size is wide, quality was further downgraded. | |
| 51 per 1000 | 53 per 1000 (8 to 294) | |||||
| Repetition of SH at 6 months' follow‐up | Study population | OR 0.75 (0.16 to 3.60) | 77 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. Lastly, as the confidence interval for the treatment effect size is wide, quality was further downgraded. | |
| 103 per 1000 | 79 per 1000 (18 to 291) | |||||
| Intensive outpatient intervention vs TAU | ||||||
| Repetition of SH at post‐intervention | Study population | OR 0.27 (0.07 to 1.06) | 119 (1 RCT) | ⊕⊕⊕⊝ Low b,c | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. Lastly, as the confidence interval for the treatment effect size is wide, quality was further downgraded. | |
| 158 per 1000 | 48 per 1000 (13 to 166) | |||||
| Repetition of SH at 24 months | Study population | OR 1.24 (0.59 to 2.62) | 126 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation. Lastly, as the confidence interval for the treatment effect size is wide, quality was further downgraded. | |
| 302 per 1000 | 349 per 1000 (203 to 531) | |||||
| Repetition of SH at final follow‐up | Study population | OR 0.65 (0.15 to 2.85) | 245 (2 RCTs) | ⊕⊝⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel could have been blind to treatment allocation. Additionally, for 1 trial, participants also were not blind to treatment allocation. We further downgraded quality due to significant differences in the direction of the effect size estimate between trials on visual inspection of the forest plot. | |
| 233 per 1000 | 165 per 1000 (44 to 464) | |||||
| Long term vs other alternative forms of psychotherapy | ||||||
| Repetition of SH at 12 months | Study population | OR 1.00 (0.35 to 2.86) | 80 (1 RCT) | ⊕⊕⊝⊝ | We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation, additionally, the method used to allocate participants to the treatment and interventions groups was not specified and as no details on allocation concealment was reported. We further downgraded quality as the sample size was small and the confidence interval for the treatment effect size is wide. | |
| 225 per 1000 | 225 per 1000 (92 to 454) | |||||
| *The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| a Risk of bias was rated as VERY SERIOUS as the nature of the intervention means that participants and clinical personnel could not have remained blind to treatment allocation, suggesting that performance and detection bias may have been present. As an open numbers table was used the generate the allocation sequence, and as allocation was not concealed, selection bias also may have been present. b Imprecision was rated as SERIOUS as the confidence interval is wide and/or the sample size is small. | ||||||
| Reference | History of SH prior to index episode (%) |
|---|---|
| 21.1 | |
| 32.3 | |
| 31.2 | |
| 34.2 | |
| 38.3 | |
| 8.9a | |
| 29.8 | |
| 36.4 | |
| aProportion with more than four previous episodes of SH over the three‐year period preceding trial entry. | |
| Reference | Methoda | ||||
|---|---|---|---|---|---|
| Self poisoning (any) n (%) | Self poisoning (pesticides) n (%) | Self injury (any) n (%) | Combined self‐poisoning and self‐injury n (%) | Unspecified n (%) | |
| 250 (76.7) | — | 64 (19.6) | — | 15 (4.6) | |
| 7,733 (89.7) | — | 158 (8.2) | — | 41 (2.1) | |
| 70 (58.3) | — | 33 (27.5) | — | 17 (14.2) | |
| 772 (100) | — | — | — | — | |
| 442 (94.6) | — | 25 (5.3) | 8 (1.7) | — | |
| 74 (71.8) | — | 25 (24.3) | — | — | |
| 808 (97.7) | — | — | — | 19 (2.3) | |
| 400 (100) | — | — | — | — | |
| 119 (100) | — | — | — | — | |
| — | — | 26 (100) | — | — | |
| 2300 (100) | — | — | — | — | |
| 471 (85.3) | — | 81 (14.7) | — | — | |
| 532 (77.8) | — | 125 (18.3) | 27 (3.9) | — | |
| 115 (68.9) | — | 41 (24.5) | 11 (6.6) | — | |
| 96 (100) | — | — | — | ||
| 80 (100) | — | — | — | ||
| 65 (29.4) | 167 (75.6) | 4 (1.8) | — | — | |
| 707 (77.3) | — | 332 (36.3) | — | 42 (4.6) | |
| 161 (37.2) | — | 57 (13.2) | — | 4 (0.9) | |
| 207 (97.6) | — | — | — | 5 (2.4) | |
| 39 (100) | — | — | — | — | |
| 141 (100) | — | — | — | — | |
| 80 (100) | — | — | — | — | |
| 605 (100) | — | — | — | — | |
| 232 (84.7) | — | — | — | 42 (15.3) | |
| 463 (89.7) | — | — | — | 53 (10.3) | |
| 77 (100) | — | — | — | — | |
| — | 120 (100) | — | — | ||
| aRefers to the methods used for the index episode. | |||||
| Reference | Psychiatric diagnosisa | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Major depression n (%) | Any other mood disorder n (%) | Any anxiety disorder n (%) | Any psychotic disorder n (%) | Post‐traumatic stress n (%) | Any eating disorder n (%) | Alcohol use disorder/dependence n (%) | Drug use disorder/dependence n (%) | Substance use disorder/dependence n (%) | Adjustment disorder n (%) | Borderline personality disorder n (%) | Any other personality disorder n (%) | |
| 130(86.7) | — | — | — | — | — | — | — | 79 (52.7) | — | — | 68 (45.3) | |
| 75 (56.0) | 103 (76.9) | 82 (61.2) | 19 (14.2) | 37 (27.6) | — | — | 72 (53.7) | — | 134 (100) | b | ||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| 92 (77.0) | — | — | — | — | — | 36 (30.0) | 48 (40.0) | 82 (68.0) | — | — | — | |
| No information on specific categories of psychiatric diagnosis reportedc | ||||||||||||
| — | 91 (42.1) | — | — | — | — | — | — | — | 62 (28.7) | — | — | |
| — | 98 (56.0)e | 60 (34.0)e | 12 (3.0) | — | — | 26 (41.0)f | — | — | — | — | ||
| No information on psychiatric diagnosis reported | ||||||||||||
| — | — | — | — | — | — | — | — | — | — | 17 (85.0) | 20 (100) | |
| — | — | — | 43 (42.1) | — | — | — | — | 13 (12.7) | — | — | — | |
| 707/827 (85.5) diagnosed with any major psychiatric disorder | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| — | — | — | — | — | — | — | — | — | — | 22 (100) | — | |
| — | 31 (50.0) | 38 (61.3) | — | 22 (35.5) | 8 (12.9) | — | — | 1 (1.6) | — | 62 (100) | b | |
| No information on psychiatric diagnosis reported | ||||||||||||
| — | 22 (83.3) | 23 (87.5) | — | — | 3 (12.5) | — | — | 11 (41.7) | — | 26 (100) | 16 (62.5) | |
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on specific categories of psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| — | 425(46.5) | — | 179(19.6) | — | — | — | — | 45 (4.9) | 191 (20.9) | — | — | |
| — | 24 (100) | — | — | — | — | — | — | — | — | — | h | |
| — | — | — | — | — | — | — | — | — | — | 44 (100) | — | |
| 73 (72.3) | — | 79 (78.2) | — | 50 (49.5) | 24 (23.8) | — | — | 30 (29.7) | — | 101(100) | b | |
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| — | 9 (23.1) | 1 (2.5) | — | — | — | 5 (12.8) | — | — | — | — | 6 (15.4) | |
| 88 (48.9) | — | 135 (75.0) | — | 71 (37.4) | 24 (13.3) | — | — | 17 (9.4) | — | 180(100) | b | |
| — | 53 (25.0) | — | — | — | — | — | — | — | — | — | ||
| No information on psychiatric diagnosis reportedi | ||||||||||||
| No information on specific categories of psychiatric diagnosis reported | ||||||||||||
| — | — | — | — | — | — | — | — | — | — | — | 80 (100) | |
| No information on psychiatric diagnosis reported | ||||||||||||
| — | 80 (88.9) | 50 (55.6) | — | — | 15 (16.7) | — | — | 15 (16.7) | — | — | — | |
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reported | ||||||||||||
| — | — | — | — | — | — | — | — | — | — | 24 (100) | — | |
| — | — | — | — | — | — | — | — | — | — | — | 471(98.1) | |
| No information on specific categories of psychiatric diagnosis reportedk | ||||||||||||
| — | 86 (31.4) | — | — | — | — | — | — | — | 40 (14.6) | — | — | |
| — | 76 (14.7) | 14 (2.7) | — | — | — | — | — | — | — | — | — | |
| No information on psychiatric diagnosis reported | ||||||||||||
| No information on psychiatric diagnosis reportedl | ||||||||||||
| — | — | — | — | — | — | — | — | — | — | 30 (100) | — | |
| No information on psychiatric diagnosis reported | ||||||||||||
| a All diagnoses represent current rather than lifetime diagnoses. | ||||||||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Repetition of SH at 6 months Show forest plot | 12 | 1317 | Odds Ratio (M‐H, Random, 95% CI) | 0.54 [0.34, 0.85] |
| 1.1.1 Individual psychotherapy | 11 | 1083 | Odds Ratio (M‐H, Random, 95% CI) | 0.52 [0.36, 0.75] |
| 1.1.2 Group‐based psychotherapy | 1 | 234 | Odds Ratio (M‐H, Random, 95% CI) | 1.35 [0.75, 2.41] |
| 1.2 Repetition of SH at 12 months Show forest plot | 10 | 2232 | Odds Ratio (M‐H, Random, 95% CI) | 0.80 [0.65, 0.98] |
| 1.2.1 Individual psychotherapy | 9 | 1799 | Odds Ratio (M‐H, Random, 95% CI) | 0.74 [0.59, 0.94] |
| 1.2.2 Group‐based psychotherapy | 1 | 433 | Odds Ratio (M‐H, Random, 95% CI) | 1.04 [0.67, 1.61] |
| 1.3 Repetition of SH at 24 months Show forest plot | 2 | 105 | Odds Ratio (M‐H, Random, 95% CI) | 0.31 [0.14, 0.69] |
| 1.3.1 Indivdual psychotherapy | 2 | 105 | Odds Ratio (M‐H, Random, 95% CI) | 0.31 [0.14, 0.69] |
| 1.4 Repetition of SH at final follow‐up Show forest plot | 17 | 2665 | Odds Ratio (M‐H, Random, 95% CI) | 0.70 [0.55, 0.88] |
| 1.4.1 Individual psychotherapy | 16 | 2232 | Odds Ratio (M‐H, Random, 95% CI) | 0.66 [0.53, 0.84] |
| 1.4.2 Group‐based psychotherapy | 1 | 433 | Odds Ratio (M‐H, Random, 95% CI) | 1.04 [0.67, 1.61] |
| 1.5 Frequency of SH at final follow‐up Show forest plot | 6 | 594 | Mean Difference (IV, Random, 95% CI) | ‐0.21 [‐0.68, 0.26] |
| 1.5.1 Individual psychotherapy | 5 | 161 | Mean Difference (IV, Random, 95% CI) | ‐0.66 [‐1.71, 0.40] |
| 1.5.2 Group‐based psychotherapy | 1 | 433 | Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.32, 0.20] |
| 1.6 Depression scores at 6 months Show forest plot | 11 | 1668 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.30 [‐0.50, ‐0.10] |
| 1.6.1 Individual psychotherapy | 10 | 1434 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.33 [‐0.56, ‐0.11] |
| 1.6.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.13 [‐0.39, 0.13] |
| 1.7 Depression scores at 12 months Show forest plot | 7 | 1130 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.64, ‐0.07] |
| 1.7.1 Individual psychotherapy | 7 | 1130 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.64, ‐0.07] |
| 1.8 Depression scores at 24 months Show forest plot | 2 | 225 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.48, 0.05] |
| 1.8.1 Individual psychotherapy | 2 | 225 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.48, 0.05] |
| 1.9 Depression scores at final follow‐up Show forest plot | 14 | 1859 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.31 [‐0.48, ‐0.14] |
| 1.9.1 Individual psychotherapy | 13 | 1625 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.35 [‐0.54, ‐0.16] |
| 1.9.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.13 [‐0.39, 0.13] |
| 1.10 Hopelessness scores at post‐intervention Show forest plot | 3 | 360 | Mean Difference (IV, Random, 95% CI) | ‐1.50 [‐3.62, 0.61] |
| 1.10.1 Individual psychotherapy | 2 | 47 | Mean Difference (IV, Random, 95% CI) | ‐4.23 [‐8.71, 0.25] |
| 1.10.2 Group‐based psychotherapy | 1 | 313 | Mean Difference (IV, Random, 95% CI) | ‐0.80 [‐2.17, 0.57] |
| 1.11 Hopelessness scores at 6 months Show forest plot | 4 | 968 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.58, ‐0.13] |
| 1.11.1 Individual psychotherapy | 3 | 734 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.48 [‐0.63, ‐0.33] |
| 1.11.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.05 [‐0.31, 0.21] |
| 1.12 Hopelessness scores at 12 months Show forest plot | 3 | 539 | Mean Difference (IV, Random, 95% CI) | ‐1.89 [‐2.97, ‐0.81] |
| 1.12.1 Individual psychotherapy | 3 | 539 | Mean Difference (IV, Random, 95% CI) | ‐1.89 [‐2.97, ‐0.81] |
| 1.13 Hopelessness scores at final follow‐up Show forest plot | 7 | 1017 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.31 [‐0.51, ‐0.10] |
| 1.13.1 Individual psychotherapy | 6 | 783 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.38 [‐0.60, ‐0.16] |
| 1.13.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.05 [‐0.31, 0.21] |
| 1.14 Suicidal ideation scores at post‐intervention Show forest plot | 3 | 360 | Mean Difference (IV, Random, 95% CI) | ‐2.52 [‐5.60, 0.56] |
| 1.14.1 Individual psychotherapy | 2 | 47 | Mean Difference (IV, Random, 95% CI) | ‐5.92 [‐11.98, 0.14] |
| 1.14.2 Group‐based psychotherapy | 1 | 313 | Mean Difference (IV, Random, 95% CI) | ‐1.50 [‐3.50, 0.50] |
| 1.15 Suicidal ideation scores at 6 months Show forest plot | 6 | 1011 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.32 [‐0.51, ‐0.13] |
| 1.15.1 Individual psychotherapy | 5 | 777 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.41 [‐0.55, ‐0.27] |
| 1.15.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.28, 0.24] |
| 1.16 Suicidal ideation scores at final follow‐up Show forest plot | 8 | 1131 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐0.47, ‐0.09] |
| 1.16.1 Individual psychotherapy | 7 | 818 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.35 [‐0.55, ‐0.15] |
| 1.16.2 Group‐based psychotherapy | 1 | 313 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.02 [‐0.24, 0.20] |
| 1.17 Proportion with improved problems at 6 months Show forest plot | 2 | 231 | Odds Ratio (M‐H, Random, 95% CI) | 2.81 [1.50, 5.24] |
| 1.17.1 Individual psychotherapy | 2 | 231 | Odds Ratio (M‐H, Random, 95% CI) | 2.81 [1.50, 5.24] |
| 1.18 Proportion with improved problems at final follow‐up Show forest plot | 2 | 211 | Odds Ratio (M‐H, Random, 95% CI) | 3.03 [0.74, 12.41] |
| 1.18.1 Individual psychotherapy | 2 | 211 | Odds Ratio (M‐H, Random, 95% CI) | 3.03 [0.74, 12.41] |
| 1.19 Problem‐solving scores at post‐intervention Show forest plot | 2 | 328 | Std. Mean Difference (IV, Random, 95% CI) | 0.15 [‐0.07, 0.36] |
| 1.19.1 Individual psychotherapy | 1 | 15 | Std. Mean Difference (IV, Random, 95% CI) | 0.29 [‐0.79, 1.37] |
| 1.19.2 Group‐based psychotherapy | 1 | 313 | Std. Mean Difference (IV, Random, 95% CI) | 0.14 [‐0.08, 0.36] |
| 1.20 Problem‐solving scores at 6 months Show forest plot | 4 | 949 | Std. Mean Difference (IV, Random, 95% CI) | 0.33 [0.08, 0.58] |
| 1.20.1 Individual psychotherapy | 3 | 715 | Std. Mean Difference (IV, Random, 95% CI) | 0.45 [0.30, 0.60] |
| 1.20.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | 0.02 [‐0.24, 0.28] |
| 1.21 Problem‐solving scores at final follow‐up Show forest plot | 5 | 958 | Std. Mean Difference (IV, Random, 95% CI) | 0.26 [0.02, 0.50] |
| 1.21.1 Individual psychotherapy | 4 | 724 | Std. Mean Difference (IV, Random, 95% CI) | 0.35 [0.04, 0.66] |
| 1.21.2 Group‐based psychotherapy | 1 | 234 | Std. Mean Difference (IV, Random, 95% CI) | 0.02 [‐0.24, 0.28] |
| 1.22 Suicide at final follow‐up Show forest plot | 15 | 2354 | Odds Ratio (M‐H, Random, 95% CI) | 0.66 [0.29, 1.51] |
| 1.22.1 Individual psychotherapy | 14 | 1921 | Odds Ratio (M‐H, Random, 95% CI) | 0.69 [0.29, 1.67] |
| 1.22.2 Group‐based psychotherapy | 1 | 433 | Odds Ratio (M‐H, Random, 95% CI) | 0.47 [0.04, 5.25] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Repetition of SH at post‐intervention Show forest plot | 9 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.1.1 Group‐based emotion‐regulation psychotherapy vs TAU | 2 | 83 | Odds Ratio (M‐H, Random, 95% CI) | 0.34 [0.13, 0.88] |
| 2.1.2 Mentalisation vs TAU | 1 | 134 | Odds Ratio (M‐H, Random, 95% CI) | 0.35 [0.17, 0.73] |
| 2.1.3 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Odds Ratio (M‐H, Random, 95% CI) | 0.05 [0.00, 0.49] |
| 2.1.4 DBT vs TAU | 3 | 267 | Odds Ratio (M‐H, Random, 95% CI) | 0.59 [0.16, 2.15] |
| 2.1.5 DBT vs treatment by expert | 1 | 97 | Odds Ratio (M‐H, Random, 95% CI) | 1.66 [0.53, 5.20] |
| 2.1.6 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Odds Ratio (M‐H, Random, 95% CI) | 0.67 [0.08, 5.68] |
| 2.2 Repetition of SH at 6 months Show forest plot | 1 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.2.1 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Odds Ratio (M‐H, Random, 95% CI) | 0.67 [0.08, 5.68] |
| 2.3 Repetition of SH at 12 months Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.3.1 DBT vs. TAU | 2 | 172 | Odds Ratio (M‐H, Random, 95% CI) | 0.36 [0.05, 2.47] |
| 2.3.2 DBT vs treatment by expert | 1 | 97 | Odds Ratio (M‐H, Random, 95% CI) | 1.18 [0.35, 3.95] |
| 2.4 Repetition of SH at final follow‐up Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.4.1 DBT vs TAU | 3 | 247 | Odds Ratio (M‐H, Random, 95% CI) | 0.57 [0.21, 1.59] |
| 2.5 Frequency of repetition of SH at post‐intervention Show forest plot | 9 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.5.1 Group‐based emotion‐regulation psychotherapy vs TAU | 2 | 83 | Mean Difference (IV, Random, 95% CI) | ‐12.76 [‐34.92, 9.40] |
| 2.5.2 Mentalisaiton vs TAU | 1 | 134 | Mean Difference (IV, Random, 95% CI) | ‐1.28 [‐2.01, ‐0.55] |
| 2.5.3 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Mean Difference (IV, Random, 95% CI) | ‐4.83 [‐7.90, ‐1.76] |
| 2.5.4 DBT vs TAU | 3 | 292 | Mean Difference (IV, Random, 95% CI) | ‐18.82 [‐36.68, ‐0.95] |
| 2.5.5 DBT vs treatment by expert | 1 | 97 | Mean Difference (IV, Random, 95% CI) | ‐14.85 [‐37.64, 7.94] |
| 2.5.6 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | ‐0.25 [‐2.47, 1.97] |
| 2.6 Frequency of repetition of SH at 6 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.6.1 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | 0.34 [‐0.61, 1.29] |
| 2.7 Number completing full course of treatment Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.7.1 Mentalisation vs TAU | 1 | 134 | Odds Ratio (M‐H, Random, 95% CI) | 0.93 [0.43, 2.02] |
| 2.7.2 DBT‐oriented therapy vs TAU | 1 | 24 | Odds Ratio (M‐H, Random, 95% CI) | 3.00 [0.53, 16.90] |
| 2.7.3 DBT prolonged exposure vs DBT standard exposure | 1 | 26 | Odds Ratio (M‐H, Random, 95% CI) | 1.14 [0.22, 5.84] |
| 2.8 Depression scores at post‐intervention Show forest plot | 8 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.8.1 Group‐based emotion‐regulation psychotherapy vs TAU | 2 | 83 | Mean Difference (IV, Random, 95% CI) | ‐9.59 [‐13.43, ‐5.75] |
| 2.8.2 Mentalisaiton vs TAU | 1 | 134 | Mean Difference (IV, Random, 95% CI) | ‐3.88 [‐6.82, ‐0.94] |
| 2.8.3 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Mean Difference (IV, Random, 95% CI) | ‐9.16 [‐14.79, ‐3.53] |
| 2.8.4 DBT vs TAU | 2 | 198 | Mean Difference (IV, Random, 95% CI) | ‐2.37 [‐6.52, 1.78] |
| 2.8.5 DBT vs treatment by expert | 1 | 89 | Mean Difference (IV, Random, 95% CI) | ‐3.00 [‐6.27, 0.27] |
| 2.8.6 DBT prolonged exposure vs DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | ‐3.70 [‐10.59, 3.19] |
| 2.9 Depression scores at 6 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.9.1 DBT prolonged exposure vs. DBT standard exposure | 1 | 18 | Mean Difference (IV, Random, 95% CI) | ‐4.30 [‐9.68, 1.08] |
| 2.10 Depression scores at 12 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.10.1 DBT vs treatment by expert | 1 | 81 | Mean Difference (IV, Random, 95% CI) | ‐1.80 [‐5.40, 1.80] |
| 2.11 Suicide ideation scores at post‐intervention Show forest plot | 2 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.11.1 DBT‐oriented therapy vs Alternative forms of psychotherapy | 1 | 24 | Mean Difference (IV, Random, 95% CI) | ‐7.75 [‐14.66, ‐0.84] |
| 2.11.2 DBT vs treatment by expert | 1 | 89 | Mean Difference (IV, Random, 95% CI) | ‐3.00 [‐13.69, 7.69] |
| 2.12 Suicide ideation scores at 12 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 2.12.1 DBT vs treatment by expert | 1 | 81 | Mean Difference (IV, Random, 95% CI) | ‐7.82 [‐18.38, 2.74] |
| 2.13 Suicide at post‐intervention Show forest plot | 3 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.13.1 DBT vs TAU | 3 | 317 | Odds Ratio (M‐H, Random, 95% CI) | 3.00 [0.12, 76.49] |
| 2.14 Suicide at 6 months Show forest plot | 1 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.14.1 DBT prolonged exposure vs DBT standard exposure | 1 | 26 | Odds Ratio (M‐H, Random, 95% CI) | 0.16 [0.01, 4.41] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Repetition of SH at post‐intervention Show forest plot | 4 | 1608 | Odds Ratio (M‐H, Random, 95% CI) | 0.78 [0.47, 1.30] |
| 3.1.1 Case management plus assertive outreach vs TAU | 3 | 843 | Odds Ratio (M‐H, Random, 95% CI) | 0.82 [0.38, 1.78] |
| 3.1.2 Case management plus assertive outreach vs enhanced usual care | 1 | 765 | Odds Ratio (M‐H, Random, 95% CI) | 0.67 [0.40, 1.10] |
| 3.2 Suicide at post‐intervention Show forest plot | 4 | 1757 | Odds Ratio (M‐H, Random, 95% CI) | 0.95 [0.57, 1.57] |
| 3.2.1 Case management plus assertive outreach vs TAU | 3 | 843 | Odds Ratio (M‐H, Random, 95% CI) | 1.77 [0.36, 8.68] |
| 3.2.2 Case management plus assertive outreach vs enhanced usual care | 1 | 914 | Odds Ratio (M‐H, Random, 95% CI) | 0.88 [0.52, 1.51] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Repetition of SH at 12 months Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 4.1.1 Adherence enhancement vs TAU | 1 | 391 | Odds Ratio (M‐H, Random, 95% CI) | 0.57 [0.32, 1.02] |
| 4.1.2 Continuity of care by the same therapist vs other alternative forms of psychotherapy | 1 | 136 | Odds Ratio (M‐H, Random, 95% CI) | 0.28 [0.07, 1.10] |
| 4.2 Depression scores at 12 months Show forest plot | 1 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 4.2.1 Continuity of care by the same therapist vs other alternative forms of psychotherapy | 1 | 127 | Mean Difference (IV, Random, 95% CI) | ‐1.40 [‐4.24, 1.44] |
| 4.3 Suicide at 12 months Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 4.3.1 Adherence enhancement vs TAU | 1 | 391 | Odds Ratio (M‐H, Random, 95% CI) | 0.85 [0.28, 2.57] |
| 4.3.2 Continuity of care by the same therapist vs other alternative forms of psychotherapy | 1 | 136 | Odds Ratio (M‐H, Random, 95% CI) | 0.62 [0.10, 3.82] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 5.1 Repetition of SH at post‐intervention Show forest plot | 8 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 5.1.1 Postcards vs TAU | 4 | 3277 | Odds Ratio (M‐H, Random, 95% CI) | 0.87 [0.62, 1.23] |
| 5.1.2 Emergency cards vs TAU | 2 | 1039 | Odds Ratio (M‐H, Random, 95% CI) | 0.82 [0.31, 2.14] |
| 5.1.3 GP letter vs TAU | 1 | 1932 | Odds Ratio (M‐H, Random, 95% CI) | 1.15 [0.93, 1.44] |
| 5.1.4 Mobile telephone‐based psychotherapy vs TAU | 1 | 68 | Odds Ratio (M‐H, Random, 95% CI) | Not estimable |
| 5.2 Repetition of SH at 12 months Show forest plot | 4 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 5.2.1 Postcards vs TAU | 2 | 2885 | Odds Ratio (M‐H, Random, 95% CI) | 0.76 [0.57, 1.02] |
| 5.2.2 Emergency cards vs TAU | 1 | 827 | Odds Ratio (M‐H, Random, 95% CI) | 1.19 [0.85, 1.67] |
| 5.2.3 Telephone contact vs TAU | 1 | 172 | Odds Ratio (M‐H, Random, 95% CI) | 1.00 [0.45, 2.23] |
| 5.3 Repetition of SH at final follow‐up Show forest plot | 7 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 5.3.1 Postcards vs TAU | 4 | 3277 | Odds Ratio (M‐H, Random, 95% CI) | 0.88 [0.62, 1.25] |
| 5.3.2 Telephone contact vs TAU | 3 | 840 | Odds Ratio (M‐H, Random, 95% CI) | 0.74 [0.42, 1.32] |
| 5.4 Frequency of SH at post‐intervention Show forest plot | 3 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 5.4.1 Postcards vs TAU | 3 | 1097 | Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.32, 0.18] |
| 5.4.2 Postcards vs TAU (males only) | 3 | 401 | Mean Difference (IV, Random, 95% CI) | ‐0.00 [‐0.13, 0.12] |
| 5.4.3 Postcards vs TAU (females only) | 3 | 695 | Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.29, 0.20] |
| 5.4.4 Postcards vs TAU (history of prior SH) | 3 | 339 | Mean Difference (IV, Random, 95% CI) | ‐0.09 [‐0.68, 0.51] |
| 5.4.5 Postcards vs TAU (no history of prior SH) | 3 | 758 | Mean Difference (IV, Random, 95% CI) | 0.23 [‐0.32, 0.77] |
| 5.5 Frequency of SH at 12 months Show forest plot | 2 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 5.5.1 Postcards vs TAU | 2 | 984 | Mean Difference (IV, Random, 95% CI) | ‐0.19 [‐0.58, 0.20] |
| 5.5.2 Postcards vs TAU (males only) | 2 | 336 | Mean Difference (IV, Random, 95% CI) | 0.03 [‐0.11, 0.16] |
| 5.5.3 Postcards vs TAU (females only) | 2 | 647 | Mean Difference (IV, Random, 95% CI) | ‐0.22 [‐0.62, 0.18] |
| 5.5.4 Postcards vs TAU (history of prior SH) | 2 | 296 | Mean Difference (IV, Random, 95% CI) | ‐0.64 [‐2.07, 0.80] |
| 5.5.5 Postcards vs TAU (no history of prior SH) | 2 | 688 | Mean Difference (IV, Random, 95% CI) | ‐0.07 [‐0.22, 0.09] |
| 5.6 Suicide at post‐intervention Show forest plot | 5 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 5.6.1 Postcards vs TAU | 4 | 3464 | Odds Ratio (M‐H, Random, 95% CI) | 1.86 [0.61, 5.72] |
| 5.6.2 Mobile telephone‐based psychotherapy vs TAU | 1 | 68 | Odds Ratio (M‐H, Random, 95% CI) | 3.09 [0.12, 78.55] |
| 5.7 Suicide at 12 months Show forest plot | 1 | 772 | Odds Ratio (M‐H, Random, 95% CI) | 0.41 [0.08, 2.15] |
| 5.7.1 Postcards vs TAU | 1 | 772 | Odds Ratio (M‐H, Random, 95% CI) | 0.41 [0.08, 2.15] |
| 5.8 Suicide at final follow‐up Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 5.8.1 Telephone contact vs TAU | 2 | 821 | Odds Ratio (M‐H, Random, 95% CI) | 0.70 [0.11, 4.33] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 6.1 Repetition of SH at final follow‐up Show forest plot | 2 | Odds Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 6.1.1 Intensive outpatient intervention vs TAU | 2 | 245 | Odds Ratio (M‐H, Random, 95% CI) | 0.65 [0.15, 2.85] |
