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AbstractObjectiveTo evaluate the clinical effectiveness of the YCMAP intervention (Youth Culturally Adapted Manual Assisted Problem Solving) for adolescents after self-harm in Pakistan.DesignMulticentre, randomised controlled trial that compared YCMAP with enhanced treatment as usual.SettingsGeneral practices, emergency departments, medical wards of participating hospitals, and community centres across Karachi, Hyderabad, Lahore, Multan, and Rawalpindi.ParticipantsAdolescents with a recent history of self-harm identified at participating health centres by treating physicians between 5 November 2019 and 31 August 2021.InterventionThe YCMAP group received up to 10 treatment sessions over three months; the intervention was based on the principles of cognitive behaviour therapy.Main outcome measureThe primary outcome was the repetition of self-harm at 12 months after randomisation. Secondary outcomes were distress, hopelessness, suicidal ideation, and health related quality of life at three, six, nine, and 12 months after randomisation. Participants’ satisfaction with the services was assessed at three and 12 months after randomisation.ResultsThis trial was conducted between November 2019 and February 2023 and included 684 adolescents randomised to YCMAP (n=342) or enhanced treatment as usual (n=342). The YCMAP group had a significantly lower risk of self-harm repetition than the enhanced treatment as usual group at 12 months after randomisation (odds ratio 0.20, 95% confidence interval 0.06 to 0.70, P=0.006). YCMAP participants showed a statistically significant reduction in distress, hopelessness, and suicidal ideation at three months, but these differences were not statistically significant at 12 months. YCMAP participants also reported significantly better quality of life and satisfaction with services at three months, with these effects sustained at all follow-up points.ConclusionThe YCMAP intervention was shown to be beneficial in self-harm prevention among adolescents. Further research and replication of findings in diverse settings are recommended to strengthen the evidence base for this public health intervention.Trial registrationClinicalTrials.gov NCT04131179 and ISRCTN registry ISRCTN57325925.

How to mitigate the dramatic increase in the number of self-inflicted deaths from suicide, alcohol-related liver disease, and drug overdose among young adults has become a critical public health question. A promising area of study looks at interventions designed to address risk factors for the behaviors that precede these —often denoted—“deaths of despair.” This paper examines whether a childhood intervention can have persistent positive effects by reducing adolescent and young adulthood (age 25) behaviors that precede these deaths, including suicidal ideation, suicide attempts, hazardous drinking, and opioid use. These analyses test the impact and mechanisms of action of Fast Track (FT), a comprehensive childhood intervention designed to decrease aggression and delinquency in at-risk kindergarteners. We find that random assignment to FT significantly decreases the probability of exhibiting any behavior of despair in adolescence and young adulthood. In addition, the intervention decreases the probability of suicidal ideation and hazardous drinking in adolescence and young adulthood as well as opioid use in young adulthood. Additional analyses indicate that FT’s improvements to children’s interpersonal (e.g., prosocial behavior, authority acceptance), intrapersonal (e.g., emotional recognition and regulation, social problem solving), and academic skills in elementary and middle school partially mediate the intervention effect on adolescent and young adult behaviors of despair and self-destruction. FT’s improvements to interpersonal skills emerge as the strongest indirect pathway to reduce these harmful behaviors. This study provides evidence that childhood interventions designed to improve these skills can decrease the behaviors associated with premature mortality.

Background Non-suicidal self-injury (NSSI) in adolescents is a significant public health issue worldwide. Dialectical Behavior Therapy (DBT) is an evidence-based intervention for treating NSSI. However, there are currently few independent studies on DBT interventions specifically targeting NSSI, particularly in Shantou city, within the Chaoshan area of southeast China. This study aimed to evaluate the effectiveness of DBT in reducing NSSI among secondary school students. Methods A total of 220 7th-grade students from four classes in two schools in Shantou City were selected using randomized cluster sampling. Two classes from one school were assigned to the DBT-based intervention group, while two classes from the other school were assigned to the control group, which received general education intervention. Comparative analyses of quantitative and categorical data were conducted using Student’s t-test and chi-square tests. Results The occurrence of NSSI in DBT group and control group was 23.60% and 24.50%, respectively. Most students who engaged in NSSI sustained mild injuries (71.43%). The occurrence of NSSI in the DBT group decreased from 23.60% to 10.91% after the DBT-based interventions ( χ 2  = 6.23, P  < 0.05). The frequency of NSSI in the DBT group was also reduced (from 1.57 ± 4.411 to 0.54 ± 1.895) after the intervention( t  = 3.628, P <0.001). In the DBT group, depression scores significantly decreased from 9.59 ± 11.15 to 6.51 ± 3.08 ( t  = 2.217, P  < 0.05). The total Sub-Optimal Health Status (SHS) score was also significantly reduced, from 16.43 ± 12.74 to 12.04 ± 7.80 ( t  = 3.083, P  < 0.05). Among its subdimensions, the psychological state score declined from 5.37 ± 4.78 to 3.70 ± 4.08 ( t  = 2.792, P  < 0.05), while the fatigue score dropped from 7.06 ± 5.28 to 5.06 ± 3.92 ( t  = 3.186, P  < 0.05). However, the control group did not show significant differences in the above aspects after the conventional interventions. Conclusions The six-month DBT-based intervention markedly reduced NSSI and improved mental-health indicators, suggesting that DBT offers an effective, scalable framework for school-based prevention in culturally diverse Chinese settings.

Background Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm. Methods This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode ( n  = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016). Results We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm ( n  = 440) and E-TAU arm ( N  = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower ( n  = 17) compared to the E-TAU arm ( n  = 23) at 12-month post-randomisation, but the difference was not statistically significant ( p  = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (− 3.6 (− 4.9, − 2.4)), depression (− 7.1 (− 8.7, − 5.4)), hopelessness (− 2.6 (− 3.4, − 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention. Conclusions Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

Hospital-treated self-poisoning is common, with limited effective interventions for reducing subsequent suicidal behaviour. To test the efficacy of a postcard intervention to reduce suicidal behaviour. Randomised controlled trial of individuals who self-poisoned (n = 2300), the intervention consisted of nine postcards sent over 12 months versus usual treatment. Outcomes assessed at 12 months (n = 2113) were suicidal ideation, suicide attempts and self-cutting (proportion and event rates). There was a significant reduction in any suicidal ideation (relative risk reduction (RRR) = 0.31, 95% CI 0.22-0.38), any suicide attempt (RRR = 0.42, 95% CI 0.11-0.63) and number of attempts (incidence rate ratios (IRR) = 0.64, 95% CI 0.42-0.97). There was no significant reduction in any self-cutting (RRR = 0.14, 95% CI -0.29 to 0.42) or self-cutting events (IRR = 1.03 95% CI 0.76-1.39). A postcard intervention reduced suicidal ideation and suicide attempts in a non-Western population. Sustained, brief contact by mail may reduce suicidal ideation and suicide attempts in individuals who self-poison.

Hospital-treated self-harm is common and costly, and is associated with repeated self-harm and suicide. To investigate the effectiveness of a brief contact intervention delivered via short message service (SMS) text messages in reducing hospital-treated self-harm re-presentations in three hospitals in Sydney (2017-2019), Australia. Trial registration number: ACTRN12617000607370. A randomised controlled trial with parallel arms allocated 804 participants presenting with self-harm, stratified by previous self-harm, to a control condition of treatment as usual (TAU) ( = 431) or an intervention condition of nine automated SMS contacts (plus TAU) ( = 373), over 12 months following the index self-harm episode. The primary outcomes were (a) repeat self-harm event rate (number of self-harm events per person per year) at 6-, 12- and 24-month follow-up and (b) the time to first repeat at 24-month follow-up. The event rate for self-harm repetition was lower for the SMS compared with TAU group at 6 months (IRR = 0.79, 95% CI 0.61-1.01), 12 months (IRR = 0.78, 95% CI 0.64-0.95) and 24 months (IRR = 0.78, 95% CI 0.66-0.91). There was no difference between the SMS and TAU groups in the time to first repeat self-harm event over 24 months (HR = 0.96, 95% CI 0.72-1.26). There were four suicides in the TAU group and none in the SMS group. The 22% reduction in repetition of hospital-treated self-harm was clinically meaningful. SMS text messages are an inexpensive, scalable and universal intervention that can be used in hospital-treated self-harm populations but further work is needed to establish efficacy and cost-effectiveness across settings.

Background Autism Adapted Safety Plans (AASP) have been proposed to help prevent self-harm and suicidality among autistic adults. The introduction of such plans not only needs to be clinically effective but also cost-effective. The aim of this work was to establish how the cost-effectiveness of AASP could be assessed. Specifically, whether tools and techniques used to collect data for health economic evaluation of the intervention are feasible and acceptable to autistic people. Methods A feasibility and external pilot randomised controlled trial of the AASP intervention was conducted. Autistic adults recruited from diverse locations in England and Wales were randomised to either: AASP and usual care, or usual care only. Health economics tools (bespoke and adapted) were developed and focus groups were undertaken with participants, including autistic adults ( n  = 15), their family members/carers ( n  = 5), and service providers ( n  = 10), to determine their acceptability and feasibility. Tools considered worth further exploration were interviewer administered to participants during the pilot trial at baseline and at 6 months. Interviewer notes were used to record any issues reported while completing the tools. Response rates on the questions and completeness of the tools, along with participant feedback in the interviewer notes was assessed. Results Standard Gamble and Time-Trade Off approaches to measure health status were judged inappropriate to measure health outcomes with autistic adults experiencing suicidal ideation and with a history of self-harm. Contingent valuation and discrete choice experiments were also considered inappropriate, due to the heavy cognitive burden on respondents. The EQ-5D-5L/VAS, resource utilisation questionnaire and time-travel questionnaire were considered acceptable by participants. Response and completion rates (as a percentage of all returned questionnaires) for resource utilisation questionnaire (> 85%), time-travel questionnaire (> 79%), EQ-5D-5L (> 96%) and EQ-5D-VAS (> 87%) were good in general. Participants needed clear guidance and interviewer support to enable questionnaire completion. Conclusions It is feasible and acceptable to collect relevant data on resource utilisation, and costs of accessing care and the EQ-5D-5L in a future definitive trial. Clear guidance and interviewer support on how to complete the questionnaires and explanations of the importance of questions to the research would help autistic participants completing the health economic tools. Trial registration ISRCTN70594445; Trial Registration Date: 06/07/2020.

Background Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia. Methods/design Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge. Discussion This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense. Trial registration and ethics approval This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370 . Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).

The increasing prevalence of mental health disorders and psychosocial distress among young people exceeds the capacity of mental health services. Social and systemic factors determine mental health as much as individual factors. To determine how best to address multi-level risk factors, we must first understand the distribution of risk. Previously, we have used psychometric methods applied to two epidemiologically-principled samples of people aged 14–24 to establish a robust, latent common mental distress (CMD) factor of depression and anxiety normally distributed across the population. This was linearly associated with suicidal thoughts and non-suicidal self-harm such that effective interventions to reduce CMD across the whole population could have a greater total benefit than those that focus on the minority with the most severe scores. In a randomised trial of mindfulness interventions in university students (the Mindful Student Study), we demonstrated a population-shift effect whereby the intervention group appeared resilient to a universal stressor. Given these findings, and in light of the COVID-19 pandemic, we argue that population-based interventions to reduce CMD are urgently required. To target all types of mental health determinants, these interventions must be multi-level. Careful design and evaluation, interdisciplinary work, and extensive local stakeholder involvement are crucial for these interventions to be effective.

BackgroundThere have been few rigorous evaluations of population, multi-strategy, suicide prevention programmes, despite increasing global recognition that such approaches are needed to reduce suicide.ObjectiveTo examine the effects of a multi-strategy suicide prevention model on age-standardised rates of hospital presenting self-harm and suicide after 24 months of implementation.MethodsA stepped-wedge cluster randomised trial was conducted in four sites across New South Wales (NSW), Australia, from 2016 to 2020. Sites were randomised to a starting order and implemented the same set of interventions over a 24-month period. Changes in rates of hospital presenting self-harm and suicide deaths were measured using linked administrative health data sets of persons aged 10 or older.ResultsNegative binomial regression models adjusted for linear trends and seasonality showed that LifeSpan was associated with a 13∙8% (incident response rate 0.86; 95% CI 0.79 to 0.94) reduction in hospital-presenting self-harm rates over the intervention period, compared with preintervention. These effects were not observed in the rest of NSW. There were statistically non-significant changes in suicide death rates during the intervention across all sites.ConclusionsLocally implementing a multi-strategy suicide prevention model can reduce rates of hospital presentations for self-harm, but longer implementation and evaluation periods may be required to realise the full impacts of interventions for suicide, as a more intractable outcome.Clinical implicationsOur findings can inform policy at all levels of government to invest in actions that may build cross-sectoral capacity in local communities to detect and respond to suicide risk.