Psychosocial interventions for self‐harm in adults

Keith Hawton; Katrina G Witt; Tatiana L Taylor Salisbury; Ella Arensman; David Gunnell; Philip Hazell; Ellen Townsend; Kees van Heeringen

doi:10.1002/14651858.CD012189

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Figure 1

Search flow diagram of included and excluded studies for the 2014 update.

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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Funnel plot of comparison 1: CBT‐based psychotherapy vs treatment as usual for repetition of SH at six months

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Figure 5

Funnel plot of comparison 1: CBT‐based psychotherapy vs treatment as usual for repetition of SH at 12 months

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Figure 6

Funnel plot of comparison 1: CBT‐based psychotherapy vs treatment as usual for repetition of SH at final follow‐up

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Figure 7

Funnel plot of comparison 1: CBT‐based psychotherapy vs Treatment as usual for depression scores at final follow‐up.

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Analysis 1.1

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 1: Repetition of SH at 6 months

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Analysis 1.2

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 2: Repetition of SH at 12 months

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Analysis 1.3

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 3: Repetition of SH at 24 months

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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

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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

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Analysis 1.6

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 6: Depression scores at 6 months

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Analysis 1.7

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 7: Depression scores at 12 months

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Analysis 1.8

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 8: Depression scores at 24 months

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Analysis 1.9

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 9: Depression scores at final follow‐up

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Analysis 1.10

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 10: Hopelessness scores at post‐intervention

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Analysis 1.11

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 11: Hopelessness scores at 6 months

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Analysis 1.12

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 12: Hopelessness scores at 12 months

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Analysis 1.13

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 13: Hopelessness scores at final follow‐up

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Analysis 1.14

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 14: Suicidal ideation scores at post‐intervention

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Analysis 1.15

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 15: Suicidal ideation scores at 6 months

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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

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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

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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

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Analysis 1.19

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 19: Problem‐solving scores at post‐intervention

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Analysis 1.20

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 20: Problem‐solving scores at 6 months

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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

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Analysis 1.22

Comparison 1: Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU), Outcome 22: Suicide at final follow‐up

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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

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Analysis 2.2

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Analysis 2.3

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Analysis 2.4

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Analysis 2.5

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Analysis 2.6

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Analysis 2.7

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Analysis 2.8

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Analysis 2.9

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Analysis 2.10

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Analysis 2.11

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Analysis 2.12

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Analysis 2.13

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Analysis 2.14

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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

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Analysis 3.2

Comparison 3: Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy, Outcome 2: Suicide at post‐intervention

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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

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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

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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

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Analysis 5.1

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 1: Repetition of SH at post‐intervention

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Analysis 5.2

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 2: Repetition of SH at 12 months

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Analysis 5.3

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 3: Repetition of SH at final follow‐up

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Analysis 5.4

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 4: Frequency of SH at post‐intervention

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Analysis 5.5

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 5: Frequency of SH at 12 months

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Analysis 5.6

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 6: Suicide at post‐intervention

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Analysis 5.7

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 7: Suicide at 12 months

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Analysis 5.8

Comparison 5: Remote contact interventions vs treatment as usual (TAU), Outcome 8: Suicide at final follow‐up

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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

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Summary of findings 1. Comparison 1: CBT‐based psychotherapy vs treatment as usual

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
CBT‐based psychotherapy vs treatment as usual for self‐harm in adults
Patient or population: adults who engage in SH Settings: outpatients Intervention: CBT‐based psychotherapy Comparison: treatment as usual (TAU)
	Assumed risk	Corresponding risk
	TAU	CBT‐based psychotherapy
Repetition of SH at post‐intervention	Study population		OR 0.66 (0.36 to 1.21)	313 (1 RCT)	⊕⊕⊝⊝ Low^a,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. We further downgraded quality as the confidence interval for the treatment effect size is wide.
Repetition of SH at post‐intervention	190 per 1000	134 per 1000 (78 to 221)	OR 0.66 (0.36 to 1.21)	313 (1 RCT)	⊕⊕⊝⊝ Low^a,b
Repetition of SH at 6 months	Study population		OR 0.54 (0.34 to 0.85)	1317 (12 RCTs)	⊕⊕⊕⊝ Moderate^a	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.
Repetition of SH at 6 months	280 per 1000	173 per 1000 (117 to 248)	OR 0.54 (0.34 to 0.85)	1317 (12 RCTs)	⊕⊕⊕⊝ Moderate^a
Repetition of SH at 12 months	Study population		OR 0.80 (0.65 to 0.98)	2232 (10 RCTs)	⊕⊕⊕⊝ Moderate^a	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.
Repetition of SH at 12 months	272 per 1000	230 per 1000 (196 to 268)	OR 0.80 (0.65 to 0.98)	2232 (10 RCTs)	⊕⊕⊕⊝ Moderate^a
Repetition of SH at 24 months	Study population		OR 0.31 (0.14 to 0.69)	105 (2 RCTs)	⊕⊕⊕⊝ Moderate^a	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.
Repetition of SH at 24 months	563 per 1000	285 per 1000 (153 to 470)	OR 0.31 (0.14 to 0.69)	105 (2 RCTs)	⊕⊕⊕⊝ Moderate^a
Repetition of SH at final follow‐up	Study population		OR 0.70 (0.55 to 0.88)	2665 (17 RCTs)	⊕⊕⊝⊝ Low^a,c	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.
Repetition of SH at final follow‐up	262 per 1000	199 per 1000 (163 to 238)	OR 0.70 (0.55 to 0.88)	2665 (17 RCTs)	⊕⊕⊝⊝ Low^a,c
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 (6 RCTs)	⊕⊕⊝⊝ Low^a,c	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) CBT: cognitive behavioural therapy; CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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 ^c We rated inconsistency as SERIOUS due to notable differences in the magnitude of the effect size estimates between trials on visual inspection of the forest plot.

Summary of findings 1. Comparison 1: CBT‐based psychotherapy vs treatment as usual

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Summary of findings 2. Comparison 2: Interventions for multiple repetition of SH/probable personality disorder vs treatment as usual or other alternative forms of psychotherapy

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 Settings: outpatients Intervention: interventions for multiple repetition of SH/probable personality disorder Comparison: treatment as usual (TAU) or other alternative forms of psychotherapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	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 (0.13 to 0.88)	83 (2 RCTs)	⊕⊕⊝⊝ Low^a	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.
Repetition of SH at post‐intervention	775 per 1000	539 per 1000 (309 to 752)	OR 0.34 (0.13 to 0.88)	83 (2 RCTs)	⊕⊕⊝⊝ Low^a
Frequency of SH at post‐intervention	Study population		—	83 (2 RCTs)	⊕⊕⊝⊝ Low^b,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 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.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average,12.76 lower (34.92 lower to 9.40 higher)		—	83 (2 RCTs)	⊕⊕⊝⊝ Low^b,c
Mentalisation vs TAU
Repetition of SH at post‐intervention	Study population		OR 0.35 (0.17 to 0.73)	134 (1 RCT)	⊕⊕⊕⊝ Moderate^b	We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation.
Repetition of SH at post‐intervention	492 per 1000	253 per 1000 (141 to 414)	OR 0.35 (0.17 to 0.73)	134 (1 RCT)	⊕⊕⊕⊝ Moderate^b
Frequency of SH at post‐intervention	Study population		—	133 (1 RCT)	⊕⊕⊕⊝ Moderate^b	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.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average,1.28 lower (2.01 lower to 0.55 lower)		—	133 (1 RCT)	⊕⊕⊕⊝ Moderate^b
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 (1 RCT)	⊕⊕⊝⊝ Low^b,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.
Repetition of SH at post‐intervention	667 per 1000	91 per 1000 (0 to 495)	OR 0.05 (0.00 to 0.49)	24 (1 RCT)	⊕⊕⊝⊝ Low^b,c
Frequency of SH at post‐intervention	Study population		—	24 (1 RCT)	⊕⊕⊝⊝ Low^b,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.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average,4.83 lower (7.90 lower to 1.76 lower)		—	24 (1 RCT)	⊕⊕⊝⊝ Low^b,c
DBT vs TAU
Repetition of SH at post‐intervention	Study population		OR 0.59 (0.16 to 2.15)	267 (3 RCTs)	⊕⊕⊝⊝ Low^b,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.
Repetition of SH at post‐intervention	667 per 1000	541 per 1000 (242 to 811)	OR 0.59 (0.16 to 2.15)	267 (3 RCTs)	⊕⊕⊝⊝ Low^b,c
Repetition of SH at 12 months' follow‐up	Study population		OR 0.36 (0.05 to 2.47)	172 (2 RCTs)	⊕⊕⊝⊝ Low^b,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.
Repetition of SH at 12 months' follow‐up	495 per 1000	260 per 1000 (47 to 707)	OR 0.36 (0.05 to 2.47)	172 (2 RCTs)	⊕⊕⊝⊝ Low^b,c
Repetition of SH at final follow‐up	Study population		OR 0.57 (0.21 to 1.59)	247 (3 RCTs)	⊕⊕⊝⊝ Low^b,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.
Repetition of SH at final follow‐up	620 per 1000	482 per 1000 (255 to 722)	OR 0.57 (0.21 to 1.59)	247 (3 RCTs)	⊕⊕⊝⊝ Low^b,c
Frequency of SH at post‐intervention	Study population		—	292 (3 RCTs)	⊕⊕⊝⊝ Low^b,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 imprecision of the effect size estimate.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average,18.82 lower (36.68 lower to 0.95 lower)		—	292 (3 RCTs)	⊕⊕⊝⊝ Low^b,c
DBT vs treatment by expert
Repetition of SH at post‐intervention	Study population		OR 1.66 (0.53 to 5.20)	97 (1 RCT)	⊕⊝⊝⊝ Very low^a,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.
Repetition of SH at post‐intervention	822 per 1000	885 per 1000 (710 to 960)	OR 1.66 (0.53 to 5.20)	97 (1 RCT)	⊕⊝⊝⊝ Very low^a,c
Repetition of SH at 12 months	Study population		OR 1.18 (0.35 to 3.95)	97 (1 RCT)	⊕⊝⊝⊝ Very low^a,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.
Repetition of SH at 12 months	867 per 1000	885 per 1000 (695 to 963)	OR 1.18 (0.35 to 3.95)	97 (1 RCT)	⊕⊝⊝⊝ Very low^a,c
Frequency of SH at post‐intervention	Study population		—	97 (1 RCT)	⊕⊝⊝⊝ Very low^a,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.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average,14.85 lower (37.64 lower to 7.94 higher)		—	97 (1 RCT)	⊕⊝⊝⊝ Very low^a,c
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)	⊕⊕⊝⊝ Low^b,c	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.
Repetition of SH at post‐intervention	333 per 1000	251 per 1000 (38 to 740)	OR 0.67 (0.08 to 5.68)	18 (1 RCT)	⊕⊕⊝⊝ Low^b,c
Repetition of SH at 6 months' follow‐up	Study population		OR 0.67 (0.08 to 5.68)	18 (1 RCT)	⊕⊕⊝⊝ Low^b,c	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.
Repetition of SH at 6 months' follow‐up	333 per 1000	251 per 1000 (38 to 740)	OR 0.67 (0.08 to 5.68)	18 (1 RCT)	⊕⊕⊝⊝ Low^b,c
Frequency of SH at post‐intervention	Study population		—	18 (1 RCT)	⊕⊕⊝⊝ Low ^b,c	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.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average,0.25 lower (2.47 lower to 1.97 higher)		—	18 (1 RCT)	⊕⊕⊝⊝ Low ^b,c
Frequency of SH at 6 months' follow‐up	Study population		—	18 (1 RCT)	⊕⊕⊝⊝ Low^b,c	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.
Frequency of SH at 6 months' follow‐up	The mean frequency of episodes of SH in the experimental group was, on average,0.34 higher (0.61 lower to 1.29 higher)		—	18 (1 RCT)	⊕⊕⊝⊝ Low^b,c
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) CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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. ^b 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 suggesting that performance and detection bias may have been present. ^c Imprecision was rated as SERIOUS as the confidence interval is wide or there are notable differences in the magnitude of the effect size between trials on visual inspection of the forest plot.

Summary of findings 2. Comparison 2: Interventions for multiple repetition of SH/probable personality disorder vs treatment as usual or other alternative forms of psychotherapy

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Summary of findings 3. Comparison 3: Case management vs treatment as usual or other alternative forms of psychotherapy

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Case management vs treatment as usual or other alternative forms of psychotherapy
Patient or population: adults who engage in SH Settings: outpatients Intervention: case management Comparison: treatment as usual (TAU) or other alternative forms of psychotherapy.
	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)	⊕⊕⊕⊝ Moderate^a	We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation.
Repetition of SH at post‐intervention	114 per 1000	91 per 1000 (57 to 143)	OR 0.78 (0.47 to 1.30)	1608 (4 RCTs)	⊕⊕⊕⊝ Moderate^a
Multiple readmissions for SH at post‐intervention	Study population		OR 5.23 (1.12 to 24.45)	469 (1 RCT)	⊕⊕⊕⊝ Moderate^a	We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel would have been blind to treatment allocation.
Multiple readmissions for SH at post‐intervention	8 per 1000	41 per 1000 (9 to 166)	OR 5.23 (1.12 to 24.45)	469 (1 RCT)	⊕⊕⊕⊝ Moderate^a
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) CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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.

Summary of findings 3. Comparison 3: Case management vs treatment as usual or other alternative forms of psychotherapy

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Summary of findings 4. Comparison 4: Adherence enhancement approaches vs treatment as usual or other alternative forms of psychotherapy

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Adherence enhancement approaches vs treatment as usual or other alternative forms of psychotherapy
Patient or population: adults who engage in SH Settings: outpatients Intervention: Adherence enhancement approaches Comparison: treatment as usual (TAU) or other alternative forms of psychotherapy
	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 (0.32 to 1.02)	391 (1 RCT)	⊕⊕⊝⊝ Low^a	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.
Repetition of SH at 12 months' follow‐up	174 per 1000	107 per 1000 (63 to 177)	OR 0.57 (0.32 to 1.02)	391 (1 RCT)	⊕⊕⊝⊝ Low^a
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)	⊕⊝⊝⊝ Very low^b,c	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.
Repetition of SH at 12 months' follow‐up	136 per 1000	42 per 1000 (11 to 148)	OR 0.28 (0.07 to 1.10)	136 (1 RCT)	⊕⊝⊝⊝ Very low^b,c
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) CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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 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. Additionally, as no details on the method used to allocate participants to the intervention and control groups or on allocation concealment were reported, selection bias also may have been present. ^c There was significant imbalance between the intervention and control groups for a number of putative risk factors for repetition of SH despite randomisation.

Summary of findings 4. Comparison 4: Adherence enhancement approaches vs treatment as usual or other alternative forms of psychotherapy

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Summary of findings 5. Comparison 5: Mixed multimodal interventions vs treatment as usual

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Mixed multimodal interventions vs treatment as usual
Patient or population: adults who engage in SH Settings: outpatients Intervention: mixed multimodal interventions Comparison: treatment as usual (TAU)
	Assumed risk	Corresponding risk
	TAU	Mixed multimodal Interventions
Mixed multimodal interventions vs TAU
Repetition of SH at post‐intervention	Study population		OR 0.98 (0.68 to 1.43)	684 (1 RCT)	⊕⊕⊝⊝ Low^a,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.
Repetition of SH at post‐intervention	204 per 1000	201 per 1000 (149 to 269)	OR 0.98 (0.68 to 1.43)	684 (1 RCT)	⊕⊕⊝⊝ Low^a,b
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)	⊕⊕⊝⊝ Low^a,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.
Repetition of SH at 12 months	403 per 1000	359 per 1000 (229 to 511)	OR 0.83 (0.44 to 1.55)	167 (1 RCT)	⊕⊕⊝⊝ Low^a,b
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) CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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.

Summary of findings 5. Comparison 5: Mixed multimodal interventions vs treatment as usual

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Summary of findings 6. Comparison 6: Remote contact interventions vs treatment as usual

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
Remote contact interventions vs treatment as usual
Patient or population: adults who engage in SH Settings: outpatients Intervention: remote contact interventions Comparison: treatment as usual
	Assumed risk	Corresponding risk
	TAU	Remote contact interventions
Postcards vs TAU
Repetition of SH at post‐intervention	Study population		OR 0.87 (0.62 to 1.23)	3277 (4 RCTs)	⊕⊝⊝⊝ Very low^a,b	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.
Repetition of SH at post‐intervention	132 per 1000	117 per 1000 (86 to 157)	OR 0.87 (0.62 to 1.23)	3277 (4 RCTs)	⊕⊝⊝⊝ Very low^a,b
Repetition of SH at 12 months	Study population		OR 0.76 (0.57 to 1.02)	2885 (2 RCTs)	⊕⊕⊕⊝ Moderate^a	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.
Repetition of SH at 12 months	175 per 1000	139 per 1000 (108 to 178)	OR 0.76 (0.57 to 1.02)	2885 (2 RCTs)	⊕⊕⊕⊝ Moderate^a
Repetition of SH at final follow‐up	Study population		OR 0.88 (0.62 to 1.25)	3277 (4 RCTs)	⊕⊝⊝⊝ Very low^a,b	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.
Repetition of SH at final follow‐up	185 per 1000	167 per 1000 (123 to 221)	OR 0.88 (0.62 to 1.25)	3277 (4 RCTs)	⊕⊝⊝⊝ Very low^a,b
Frequency of SH at post‐intervention	Study population		—	1097 (3 RCTs)	⊕⊝⊝⊝ Very low^a,b	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.
Frequency of SH at post‐intervention	The mean frequency of episodes of SH in the experimental group was, on average, 0.07 lower (0.32 lower to 0.18 higher)		—	1097 (3 RCTs)	⊕⊝⊝⊝ Very low^a,b
Frequency of SH at 12 months	Study population		—	984 (2 RCTs)	⊕⊝⊝⊝ Very low^a,b	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.
Frequency of SH at 12 months	The mean frequency of episodes of SH in the experimental group was, on average, 0.19 lower (0.58 lower to 0.20 higher)		—	984 (2 RCTs)	⊕⊝⊝⊝ Very low^a,b
Frequency of SH at 24 months	Study population		—	472 (1 RCT)	⊕⊕⊕⊝ Moderate^a	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.
Frequency of SH at 24 months	The mean frequency of episodes of SH in the experimental group was, on average, 0.03 lower (0.16 lower to 0.10 higher)		—	472 (1 RCT)	⊕⊕⊕⊝ Moderate^a
Emergency cards vs TAU
Repetition of SH at post‐intervention	Study population		OR 0.82 (0.31 to 2.14)	1039 (2 RCTs)	⊕⊕⊝⊝ Low^a,d	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.
Repetition of SH at post‐intervention	171 per 1000	145 per 1000 (60 to 306)	OR 0.82 (0.31 to 2.14)	1039 (2 RCTs)	⊕⊕⊝⊝ Low^a,d
Repetition of SH at 12 months' follow‐up	Study population		OR 1.19 (0.85 to 1.67)	827 (1 RCT)	⊕⊕⊕⊝ Moderate ^a	We downgraded quality as the nature of this intervention means it is unlikely participants and clinical personnel were bind to treatment allocation.
Repetition of SH at 12 months' follow‐up	188 per 1000	216 per 1000 (164 to 279)	OR 1.19 (0.85 to 1.67)	827 (1 RCT)	⊕⊕⊕⊝ Moderate ^a
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)	⊕⊕⊕⊝ Moderate^a	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.
Repetition of SH at post‐intervention	195 per 1000	218 per 1000 (184 to 259)	OR 1.15 (0.93 to 1.44)	1932 (1 RCT)	⊕⊕⊕⊝ Moderate^a
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)	⊕⊕⊝⊝ Low^a,e	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.
Repetition of SH at 6 months' follow‐up	100 per 1000	25 per 1000 (2 to 190)	OR 0.23 (0.02 to 2.11)	81 (1 RCT)	⊕⊕⊝⊝ Low^a,e
Repetition of SH at 12 months' follow‐up	Study population		OR 1.00 (0.45 to 2.23)	172 (1 RCT)	⊕⊕⊝⊝ Low ^a,e	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.
Repetition of SH at 12 months' follow‐up	169 per 1000	169 per 1000 (84 to 311)	OR 1.00 (0.45 to 2.23)	172 (1 RCT)	⊕⊕⊝⊝ Low ^a,e
Repetition of SH at 24 months' follow‐up	Study population		OR 0.76 (0.49 to 1.16)	605 (1 RCT)	⊕⊕⊕⊝ Low^a,e	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.
Repetition of SH at 24 months' follow‐up	189 per 1000	151 per 1000 (103 to 213)	OR 0.76 (0.49 to 1.16)	605 (1 RCT)	⊕⊕⊕⊝ Low^a,e
Repetition of SH at final follow‐up	Study population		OR 0.74 (0.42 to 1.32)	840 (3 RCTs)	⊕⊝⊝⊝ Very low^a,b	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.
Repetition of SH at final follow‐up	185 per 1000	143 per 1000 (87 to 230)	OR 0.74 (0.42 to 1.32)	840 (3 RCTs)	⊕⊝⊝⊝ Very low^a,b
Mobile telephone‐based psychotherapy vs TAU
Repetition of SH at post‐intervention	Study population		Not estimable	68 (1 RCT)	⊕⊕⊝⊝ Low^a,e	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.
Repetition of SH at post‐intervention	0 per 1000	0 per 1000 (0 to 0)	Not estimable	68 (1 RCT)	⊕⊕⊝⊝ Low^a,e
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) CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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. ^b Inconsistency was rated as VERY SERIOUS as the confidence interval is wide or there are significant differences in the magnitude of the effect size between trials on visual inspection of the forest plot. ^c 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. Additionally, for some trials, no details on outcome assessor blinding were reported. Performance and detection bias therefore cannot be ruled out. Additionally, as a number of participants randomised to the control group mistakenly received the intervention, and yet were included in the control group for all subsequent analyses, other bias may have been present. ^d Inconsistency was rated as SERIOUS as the confidence interval is wide or there are notable differences in the magnitude of the effect size between trials on visual inspection of the forest plot. ^e Imprecision was rated as SERIOUS as the confidence interval is wide and/or the sample size is small.

Summary of findings 6. Comparison 6: Remote contact interventions vs treatment as usual

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Summary of findings 7. Comparison 7: Other mixed interventions vs treatment as usual or other alternative form of psychotherapy

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
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 Comparison: treatment as usual or other alternative forms of psychotherapy
	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)	⊕⊝⊝⊝ Very low^a,b	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.
Repetition of SH at 12 months	250 per 1000	118 per 1000 (20 to 461)	OR 0.40 (0.06 to 2.57)	33 (1 RCT)	⊕⊝⊝⊝ Very low^a,b
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)	⊕⊕⊝⊝ Low^b,c	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.
Repetition of SH at 12 months	250 per 1000	167 per 1000 (26 to 597)	OR 0.60 (0.08 to 4.45)	24 (1 RCT)	⊕⊕⊝⊝ Low^b,c
Information and support vs TAU
Repetition of SH at final follow‐up for the overall cohort	Study population		OR 1.02 (0.71 to 1.47)	1663 (1 RCT)	⊕⊕⊝⊝ Low^d	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 (54 to 106)	OR 1.02 (0.71 to 1.47)	1663 (1 RCT)	⊕⊕⊝⊝ Low^d
Repetition of SH at final follow‐up for the Campinas, Brazil site	Study population		OR 2.27 (0.97 to 5.28)	135 (1 RCT)	⊕⊝⊝⊝ Very low^b,c	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 (152 to 494)	OR 2.27 (0.97 to 5.28)	135 (1 RCT)	⊕⊝⊝⊝ Very low^b,c
Repetition of SH at final follow‐up for the Colombo, Sri Lanka site	Study population		OR 0.55 (0.13 to 2.34)	251 (1 RCT)	⊕⊝⊝⊝ Very low^b,d	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 (6 to 92)	OR 0.55 (0.13 to 2.34)	251 (1 RCT)	⊕⊝⊝⊝ Very low^b,d
Repetition of SH at final follow‐up for the Karaj, Iran site	Study population		OR 1.18 (0.69 to 2)	601 (1 RCT)	⊕⊕⊝⊝ Low^d	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 (67 to 172)	OR 1.18 (0.69 to 2)	601 (1 RCT)	⊕⊕⊝⊝ Low^d
Repetition of SH at final follow‐up for the Yuncheng, China site	Study population		OR 2.01 (0.08 to 50.6)	96 (1 RCT)	⊕⊝⊝⊝ Very low^b,d	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 (0 to 0)	OR 2.01 (0.08 to 50.6)	96 (1 RCT)	⊕⊝⊝⊝ Very low^b,d
Repetition of SH at final follow‐up for the Chennai, India site	Study population		OR 0.39 (0.17 to 0.92)	561 (1 RCT)	⊕⊕⊝⊝ Low^d	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 (12 to 60)	OR 0.39 (0.17 to 0.92)	561 (1 RCT)	⊕⊕⊝⊝ Low^d
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 (1 RCT)	⊕⊕⊝⊝ Low^d	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)	⊕⊕⊝⊝ 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. We further downgraded quality as the confidence interval for the treatment effect size is wide.
Repetition of SH at 6 months	216 per 1000	136 per 1000 (52 to 306)	OR 0.57 (0.20 to 1.60)	103 (1 RCT)	⊕⊕⊝⊝ Low^b,c
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)	⊕⊕⊝⊝ 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. We further downgraded quality as the confidence interval for the treatment effect size is wide.
Repetition of SH at 12 months	146 per 1000	104 per 1000 (33 to 284)	OR 0.68 (0.20 to 2.32)	96 (1 RCT)	⊕⊕⊝⊝ Low^b,c
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)	⊕⊕⊝⊝ 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. We further downgraded quality as the confidence interval for the treatment effect size is wide.
Repetition of SH at 12 months	149 per 1000	172 per 1000 (98 to 283)	OR 1.18 (0.62 to 2.25)	274 (1 RCT)	⊕⊕⊝⊝ Low ^b,c
Frequency of SH at 12 months	Study population		—	274 (1 RCT)	⊕⊕⊕⊝ Moderate^c	We downgraded quality as the nature of this intervention means it is unlikely clinical personnel would have been blind to treatment allocation.
Frequency of SH at 12 months	The mean frequency of SH at 12 months in the control group was 0.23 episodes	The mean frequency of SH at 12 months in the experimental group was 0 higher (0.17 lower to 0.17 higher	—	274 (1 RCT)	⊕⊕⊕⊝ Moderate^c
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)	⊕⊕⊝⊝ 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.
Repetition of SH at post‐intervention	51 per 1000	53 per 1000 (8 to 294)	OR 1.03 (0.14 to 7.69)	77 (1 RCT)	⊕⊕⊝⊝ Low^b,c
Repetition of SH at 6 months' follow‐up	Study population		OR 0.75 (0.16 to 3.60)	77 (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.
Repetition of SH at 6 months' follow‐up	103 per 1000	79 per 1000 (18 to 291)	OR 0.75 (0.16 to 3.60)	77 (1 RCT)	⊕⊕⊝⊝ Low^b,c
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.
Repetition of SH at post‐intervention	158 per 1000	48 per 1000 (13 to 166)	OR 0.27 (0.07 to 1.06)	119 (1 RCT)	⊕⊕⊕⊝ Low ^b,c
Repetition of SH at 24 months	Study population		OR 1.24 (0.59 to 2.62)	126 (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.
Repetition of SH at 24 months	302 per 1000	349 per 1000 (203 to 531)	OR 1.24 (0.59 to 2.62)	126 (1 RCT)	⊕⊕⊝⊝ Low ^b,c
Repetition of SH at final follow‐up	Study population		OR 0.65 (0.15 to 2.85)	245 (2 RCTs)	⊕⊝⊝⊝ Very low^b,e	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.
Repetition of SH at final follow‐up	233 per 1000	165 per 1000 (44 to 464)	OR 0.65 (0.15 to 2.85)	245 (2 RCTs)	⊕⊝⊝⊝ Very low^b,e
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)	⊕⊕⊝⊝ 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, 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.
Repetition of SH at 12 months	225 per 1000	225 per 1000 (92 to 454)	OR 1.00 (0.35 to 2.86)	80 (1 RCT)	⊕⊕⊝⊝ Low ^b,c
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) CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial: SH: self‐harm; TAU: treatment as usual.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
^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. ^c Risk of bias was rated as SERIOUS as clinical personnel were not blind to treatment allocation, suggesting that performance and detection bias may have been present. Additionally, although details on participant blinding and outcome assessor blinding were not adequately described, the nature of the intervention means that participants could not have remained blind to treatment allocation. Finally, authors of some studies did not adequately describe details on sequence generation and allocation concealment. Selection bias therefore may also have been present. ^d 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. Additionally, attrition bias may have been present. ^e Inconsistency was rated as VERY SERIOUS due to significant differences in the magnitude of the effect size between trials on visual inspection of the forest plot.

Summary of findings 7. Comparison 7: Other mixed interventions vs treatment as usual or other alternative form of psychotherapy

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Table 1. Proportion of the sample with a history of self‐harm prior to the index attempt

Reference	History of SH prior to index episode (%)
Fleischmann 2008	21.1
Hawton 1981	32.3
Hawton 1987a	31.2
Hassanian‐Moghaddam 2011	34.2
Hvid 2011	38.3
Vaiva 2006	8.9^a
Van Heeringen 1995	29.8
Waterhouse 1990	36.4
^aProportion with more than four previous episodes of SH over the three‐year period preceding trial entry.

Table 1. Proportion of the sample with a history of self‐harm prior to the index attempt

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Table 2. Methods used for the index episode of self‐harm in included studies

Reference	Method^a
Reference	Self poisoning (any) n (%)	Self poisoning (pesticides) n (%)	Self injury (any) n (%)	Combined self‐poisoning and self‐injury n (%)	Unspecified n (%)
Beautrais 2010^b	250 (76.7)	—	64 (19.6)	—	15 (4.6)
Bennewith 2002	7,733 (89.7)	—	158 (8.2)	—	41 (2.1)
Brown 2005	70 (58.3)	—	33 (27.5)	—	17 (14.2)
Carter 2005	772 (100)	—	—	—	—
Clarke 2002^b	442 (94.6)	—	25 (5.3)	8 (1.7)	—
Crawford 2010^c	74 (71.8)	—	25 (24.3)	—	—
Evans 1999a	808 (97.7)	—	—	—	19 (2.3)
Gibbons 1978	400 (100)	—	—	—	—
Guthrie 2001	119 (100)	—	—	—	—
Harned 2014	—	—	26 (100)	—	—
Hassanian‐Moghaddam 2011	2300 (100)	—	—	—	—
Hatcher 2011	471 (85.3)	—	81 (14.7)	—	—
Hatcher 2015	532 (77.8)	—	125 (18.3)	27 (3.9)	—
Hatcher 2016a	115 (68.9)	—	41 (24.5)	11 (6.6)	—
Hawton 1981	96 (100)	—		—	—
Hawton 1987a	80 (100)	—		—	—
Husain 2014^b	65 (29.4)	167 (75.6)	4 (1.8)	—	—
Kawanishi 2014^b	707 (77.3)	—	332 (36.3)	—	42 (4.6)
McAuliffe 2014^d	161 (37.2)	—	57 (13.2)	—	4 (0.9)
Morgan 1993	207 (97.6)	—	—	—	5 (2.4)
McLeavey 1994	39 (100)	—	—	—	—
Torhorst 1987	141 (100)	—	—	—	—
Torhorst 1988	80 (100)	—	—	—	—
Vaiva 2006	605 (100)	—	—	—	—
Van der Sande 1997a	232 (84.7)	—	—	—	42 (15.3)
Van Heeringen 1995	463 (89.7)	—	—	—	53 (10.3)
Waterhouse 1990	77 (100)	—	—	—	—
Welu 1977		—	120 (100)	—	—
^aRefers to the methods used for the index episode. ^b Percentages are greater than 100% because participants may have used multiple methods. ^c The remaining four (3.9%) participants used multiple, unspecified methods. ^d Methods of self‐harm for the remaining 211 (48.7%) participants were not provided.

Table 2. Methods used for the index episode of self‐harm in included studies

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Table 3. Major categories of psychiatric diagnoses in included studies

Reference	Psychiatric diagnosis^a
Reference	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 (%)
Allard 1992	130(86.7)	—	—	—	—	—	—	—	79 (52.7)	—	—	68 (45.3)
Bateman 2009	75 (56.0)	103 (76.9)	82 (61.2)		19 (14.2)	37 (27.6)	—	—	72 (53.7)	—	134 (100)	^b
Beautrais 2010	No information on psychiatric diagnosis reported
Bennewith 2002	No information on psychiatric diagnosis reported
Brown 2005	92 (77.0)	—	—	—	—	—	36 (30.0)	48 (40.0)	82 (68.0)	—	—	—
Carter 2005	No information on specific categories of psychiatric diagnosis reported^c
Cedereke 2002^d	—	91 (42.1)	—	—	—	—	—	—	—	62 (28.7)	—	—
Clarke 2002	—	98 (56.0)^e	60 (34.0)^e	12 (3.0)	—	—	26 (41.0)^f	—	—	—	—
Crawford 2010	No information on psychiatric diagnosis reported
Davidson 2014	—	—	—	—	—	—	—	—	—	—	17 (85.0)	20 (100)
Dubois 1999	—	—	—	43 (42.1)	—	—	—	—	13 (12.7)	—	—	—
Evans 1999a	707/827 (85.5) diagnosed with any major psychiatric disorder
Evans 1999b	No information on psychiatric diagnosis reported
Fleischmann 2008	No information on psychiatric diagnosis reported
Gibbons 1978	No information on psychiatric diagnosis reported
Gratz 2006	—	—	—	—	—	—	—	—	—	—	22 (100)	—
Gratz 2014	—	31 (50.0)	38 (61.3)	—	22 (35.5)	8 (12.9)	—	—	1 (1.6)	—	62 (100)	^b
Guthrie 2001	No information on psychiatric diagnosis reported
Harned 2014	—	22 (83.3)	23 (87.5)	—	—	3 (12.5)	—	—	11 (41.7)	—	26 (100)	16 (62.5)
Hassanian‐Moghaddam 2011	No information on psychiatric diagnosis reported
Hatcher 2011	No information on psychiatric diagnosis reported
Hatcher 2015	No information on psychiatric diagnosis reported
Hatcher 2016a	No information on psychiatric diagnosis reported
Hawton 1981	No information on psychiatric diagnosis reported
Hawton 1987a	No information on psychiatric diagnosis reported
Husain 2014	No information on psychiatric diagnosis reported
Hvid 2011	No information on specific categories of psychiatric diagnosis reported
Kapur 2013a	No information on psychiatric diagnosis reported
Kawanishi 2014^g	—	425(46.5)	—	179(19.6)	—	—	—	—	45 (4.9)	191 (20.9)	—	—
Liberman 1981	—	24 (100)	—	—	—	—	—	—	—	—	—	^h
Linehan 1991	—	—	—	—	—	—	—	—	—	—	44 (100)	—
Linehan 2006	73 (72.3)	—	79 (78.2)	—	50 (49.5)	24 (23.8)	—	—	30 (29.7)	—	101(100)	^b
Marasinghe 2012	No information on psychiatric diagnosis reported
McAuliffe 2014	No information on psychiatric diagnosis reported
McLeavey 1994	—	9 (23.1)	1 (2.5)	—	—	—	5 (12.8)	—	—	—	—	6 (15.4)
McMain 2009	88 (48.9)	—	135 (75.0)	—	71 (37.4)	24 (13.3)	—	—	17 (9.4)	—	180(100)	^b
Morgan 1993	—	53 (25.0)	—	—	—	—	—	—	—	—	—
Morthorst 2012	No information on psychiatric diagnosis reportedⁱ
Patsiokas 1985	No information on specific categories of psychiatric diagnosis reported
Priebe 2012^j	—	—	—	—	—	—	—	—	—	—	—	80 (100)
Salkovskis 1990	No information on psychiatric diagnosis reported
Slee 2008	—	80 (88.9)	50 (55.6)	—	—	15 (16.7)	—	—	15 (16.7)	—	—	—
Stewart 2009	No information on psychiatric diagnosis reported
Tapolaa 2010	No information on psychiatric diagnosis reported
Torhorst 1987	No information on psychiatric diagnosis reported
Torhorst 1988	No information on psychiatric diagnosis reported
Turner 2000	—	—	—	—	—	—	—	—	—	—	24 (100)	—
Tyrer 2003	—	—	—	—	—	—	—	—	—	—	—	471(98.1)
Vaiva 2006	No information on specific categories of psychiatric diagnosis reported^k
Van der Sande 1997a	—	86 (31.4)	—	—	—	—	—	—	—	40 (14.6)	—	—
Van Heeringen 1995	—	76 (14.7)	14 (2.7)	—	—	—	—	—	—	—	—	—
Waterhouse 1990	No information on psychiatric diagnosis reported
Wei 2013	No information on psychiatric diagnosis reported^l
Weinberg 2006	—	—	—	—	—	—	—	—	—	—	30 (100)	—
Welu 1977	No information on psychiatric diagnosis reported
^a All diagnoses represent current rather than lifetime diagnoses. ^b As participants could be diagnosed with more than one axis II diagnosis, the absolute number of participants diagnosed with any other personality disorder in this trial is unclear. ^c Median number (interquartile range) of psychiatric diagnoses in the both the intervention and control groups was 2 (1‐3). Information on specific categories of psychiatric diagnosis; however, were not reported. ^d A total of 47/216 (21.7%) of the sample were diagnosed with any psychiatric disorder other than a mood or adjustment disorder. ^e Diagnosed with a possible psychiatric disorder according to cut‐off scores on the Hamilton Anxiety and Depression Scale (HADS). Out of a total of 176 participants with complete ratings on this instrument. ^f Diagnosed with problematic alcohol use according to cut‐off scores on the Alcohol Use Disorders Identification Test (AUDIT). Out of a total of 63 participants with complete ratings on this instrument. ^g An additional 73/914 (8.0%) were diagnosed with any other major psychiatric disorder. ^h The authors state that "[m]ost patients would have been given personality disorder designations. . . including histrionic, narcissistic, borderline, avoidant, and dependent types" (p.1127). The absolute number of participants diagnosed with any one of these personality disorders in this trial is, however, unclear. ⁱ A total of 14/243 (5.8%) participants had been admitted to a psychiatric inpatient ward in the four weeks prior to the index suicide attempt. These patients were therefore likely to have been diagnosed with a current major psychiatric illness. ^j Mean (standard deviation (SD)) number of axis I psychiatric disorders was 8.0 (3.1) (n = 63) and mean (SD) number of axis II diagnoses was 3.5 (1.6) (n = 80). ^k A total of 100/459 (21.8%) of participants had, however, been referred for psychiatric treatment at the time of the index suicide attempt. These patients were therefore likely to have been diagnosed with a current major psychiatric illness. ^l A total of 166/239 (69.4%) were, however, diagnosed with a major psychiatric illness according to DSM‐IV‐TR criteria.

Table 3. Major categories of psychiatric diagnoses in included studies

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Comparison 1. Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU)

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]

Comparison 1. Cognitive behavioural therapy (CBT)‐based psychotherapy vs. treatment as usual (TAU)

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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 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]

Comparison 2. Interventions for multiple repetition of self‐harm (SH)/probable personality disorder vs treatment as usual (TAU) or other alternative forms of psychotherapy

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Comparison 3. Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy

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]

Comparison 3. Case management vs treatment as usual (TAU) or other alternative forms of psychotherapy

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Comparison 4. Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy

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]

Comparison 4. Treatment adherence enhancement approaches vs treatment as usual (TAU) or other alternative forms of psychotherapy

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Comparison 5. Remote contact interventions vs treatment as usual (TAU)

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]

Comparison 5. Remote contact interventions vs treatment as usual (TAU)

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Comparison 6. Other mixed interventions versus treatment as usual (TAU) or other alternative forms of psychotherapy

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]

Comparison 6. Other mixed interventions versus treatment as usual (TAU) or other alternative forms of psychotherapy

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