Bahji Anees, Pierce Matthew, Wong Jennifer, Roberge Johanne N, Ortega Iliana, Patten Scott
Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.
Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.
JAMA Netw Open. 2021 Apr 1;4(4):e216614. doi: 10.1001/jamanetworkopen.2021.6614.
Self-harm and suicidal behavior are associated with substantial morbidity and mortality among children and adolescents. The comparative performance of psychotherapies for suicidality is unclear because few head-to-head clinical trials have been conducted.
To compare the efficacy of psychotherapies for the treatment of self-harm and suicidality among children and adolescents.
Four major bibliographic databases (PubMed, MEDLINE, PsycINFO, and Embase) were searched for clinical trials comparing psychotherapy with control conditions from inception to September 2020.
Randomized clinical trials comparing psychotherapies for suicidality and/or self-harm with control conditions among children and adolescents were included after a blinded review by 3 independent reviewers (A.B., M.P., and J.W.).
The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed for data abstraction, and the Cochrane risk of bias tool was used to evaluate study-level risk of bias. Data abstraction was performed by 1 reviewer (A.B.) and confirmed by 2 independent blinded reviewers (J.W. and M.P.). Data were analyzed from October 15, 2020, to February 15, 2021.
The primary outcomes were dichotomized self-harm and retention in treatment. The secondary outcomes were dichotomized all-cause treatment discontinuation and scores on instruments measuring suicidal ideation and depressive symptoms. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary odds ratios (ORs) and Cohen d standardized mean differences (SMDs). Negative Cohen d SMDs or ORs less than 1 indicated that the treatment reduced the parameter of interest relative to the control condition (eg, signifying a beneficial association with suicidal ideation).
The systematic search generated 1272 unique records. Of those, 44 randomized clinical trials (5406 total participants; 4109 female participants [76.0%]) from 49 articles were selected (5 follow-up studies were merged with their primary clinical trials to avoid publication bias). The selected clinical trials spanned January 1, 1995, to December 31, 2020. The median duration of treatment was 3 months (range, 0.25-12.00 months), and the median follow-up period was 12 months (range, 1-36 months). None of the investigated psychotherapies were associated with increases in study withdrawals or improvements in retention in treatment compared with treatment as usual. Dialectical behavioral therapies were associated with reductions in self-harm (OR, 0.28; 95% CI, 0.12-0.64) and suicidal ideation (Cohen d SMD, -0.71; 95% CI, -1.19 to -0.23) at the end of treatment, while mentalization-based therapies were associated with decreases in self-harm (OR, 0.38; 95% CI, 0.15-0.97) and suicidal ideation (Cohen d SMD, -1.22; 95% CI, -2.18 to -0.26) at the end of follow-up. The quality of evidence was downgraded because of high risk of bias overall, heterogeneity, publication bias, inconsistency, and imprecision.
Although some psychotherapeutic modalities appear to be acceptable and efficacious for reducing self-harm and suicidality among children and adolescents, methodological issues and high risk of bias prevent a consistent estimate of their comparative performance.
自我伤害和自杀行为与儿童及青少年的高发病率和死亡率相关。由于几乎没有进行过直接比较的临床试验，因此心理治疗对自杀倾向的相对疗效尚不清楚。
比较心理治疗对儿童及青少年自我伤害和自杀倾向的治疗效果。
检索了四个主要的文献数据库（PubMed、MEDLINE、PsycINFO和Embase），以查找从数据库建立至2020年9月期间比较心理治疗与对照情况的临床试验。
由3名独立评审员（A.B.、M.P.和J.W.）进行盲审后，纳入比较儿童及青少年自杀倾向和/或自我伤害的心理治疗与对照情况的随机临床试验。
数据提取遵循系统评价和Meta分析的首选报告项目（PRISMA）报告指南，并使用Cochrane偏倚风险工具评估研究层面的偏倚风险。数据提取由1名评审员（A.B.）完成，并由2名独立的盲审员（J.W.和M.P.）确认。数据分析于2020年10月15日至2021年2月15日进行。
主要结局为自我伤害的二分法和治疗保留率。次要结局为全因治疗中断的二分法以及测量自杀意念和抑郁症状的工具得分。效应量使用频率学派随机效应网络Meta分析模型进行合并，以生成汇总比值比（OR）和Cohen d标准化均数差（SMD）。负的Cohen d SMD或小于1的OR表明，相对于对照情况，该治疗降低了感兴趣的参数（例如，表示与自杀意念存在有益关联）。
系统检索共获得1272条独特记录。其中，从49篇文章中选取了44项随机临床试验（共5406名参与者；4109名女性参与者[76.0%]）（5项随访研究与其主要临床试验合并，以避免发表偏倚）。所选临床试验涵盖1995年1月1日至2020年12月31日。治疗的中位持续时间为3个月（范围：0.25 - 12.00个月），中位随访期为12个月（范围：1 - 36个月）。与常规治疗相比，所研究的心理治疗均未导致研究退出增加或治疗保留率改善。辩证行为疗法与治疗结束时自我伤害的减少（OR = 0.28；95%CI：0.12 - 0.64）和自杀意念的减少（Cohen d SMD = -0.71；95%CI：-1.19至-0.23）相关，而基于心理化的疗法与随访结束时自我伤害的减少（OR = 0.38；95%CI：0.15 - 0.97）和自杀意念的减少（Cohen d SMD = -1.22；95%CI：-2.18至-0.
