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Background
Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic framework that appears promising to reduce suicidal ideation and suicidal cognition. CAMS has not previously been evaluated in a standard specialized mental health care setting for patients with suicidal problems in general. In this pragmatic randomized contro...
Context in source publication
Context 1
... therapists in CAMS and TAU are skilled psycholo- gists or psychiatrists; some are specialists in their field. Thirty therapists (CAMS and TAU) are currently actively participating in the study (see Table 3). The CAMS therapist group now consists of nine adherence approved participants, where eight are psychologists and one is a psychiatrist. ...
Citations
... The Suicide Attempt and Self-Injury Count, a brief version of the Suicide Attempt Self-Injury Interview [44], has been widely used to determine suicide attempts in clinical trials [45][46][47][48][49] and was used to identify dates of suicide events and categorize events into suicide attempts and nonsuicidal acts. ...
Background
Despite decades of research to better understand suicide risk and to develop detection and prevention methods, suicide is still one of the leading causes of death globally. While large-scale studies using real-world evidence from electronic health records can identify who is at risk, they have not been successful at pinpointing when someone is at risk. Personalized social media and online search history data, by contrast, could provide an ongoing real-world datastream revealing internal thoughts and personal states of mind.
Objective
We conducted this study to determine the feasibility and acceptability of using personalized online information-seeking behavior in the identification of risk for suicide attempts.
Methods
This was a cohort survey study to assess attitudes of participants with a prior suicide attempt about using web search data for suicide prevention purposes, dates of lifetime suicide attempts, and an optional one-time download of their past web searches on Google. The study was conducted at the University of Washington School of Medicine Psychiatry Research Offices. The main outcomes were participants’ opinions on internet search data for suicide prediction and intervention and any potential change in online information-seeking behavior proximal to a suicide attempt. Individualized nonparametric association analysis was used to assess the magnitude of difference in web search data features derived from time periods proximal (7, 15, 30, and 60 days) to the suicide attempts versus the typical (baseline) search behavior of participants.
Results
A total of 62 participants who had attempted suicide in the past agreed to participate in the study. Internet search activity varied from person to person (median 2-24 searches per day). Changes in online search behavior proximal to suicide attempts were evident up to 60 days before attempt. For a subset of attempts (7/30, 23%) search features showed associations from 2 months to a week before the attempt. The top 3 search constructs associated with attempts were online searching patterns (9/30 attempts, 30%), semantic relatedness of search queries to suicide methods (7/30 attempts, 23%), and anger (7/30 attempts, 23%). Participants (40/59, 68%) indicated that use of this personalized web search data for prevention purposes was acceptable with noninvasive potential interventions such as connection to a real person (eg, friend, family member, or counselor); however, concerns were raised about detection accuracy, privacy, and the potential for overly invasive intervention.
Conclusions
Changes in online search behavior may be a useful and acceptable means of detecting suicide risk. Personalized analysis of online information-seeking behavior showed notable changes in search behavior and search terms that are tied to early warning signs of suicide and are evident 2 months to 7 days before a suicide attempt.
... These drivers are derived from various theoretical works by Schneidman, Beaumeister and Beck. 4,7 The work collaboratively identifies and discusses reasons for living and reasons for dying. The goal is to build motivation to live and minimise drivers of suicide. ...
... CAMS clinicians take an empathic approach when supporting consumers and engage in collaborative, nonjudgemental, suicide prevention focussed problem solving. 4,7 The subsequent development of the suicide focussed treatment plan addressing the five key drivers involves collaborative problem solving techniques to reduce risk and build resilience. 7 Several studies have evaluated the efficacy and effectiveness of CAMS, but there have been no published systematic reviews. ...
... 4,7 The subsequent development of the suicide focussed treatment plan addressing the five key drivers involves collaborative problem solving techniques to reduce risk and build resilience. 7 Several studies have evaluated the efficacy and effectiveness of CAMS, but there have been no published systematic reviews. The outcome of interest in our systematic review was the efficacy of CAMS in reducing morbidity and mortality from suicidality and suicidal acts in adults. ...
Objective: Evaluate the efficacy of Collaborative Assessment and Management of Suicidality (CAMS) in managing suicide risk and deliberate self-harm in adults.
Methods: Ten databases were searched for publications referring to CAMS or the Suicide Status Form. Results were evaluated by two reviewers.
Results: Limited evidence that CAMS is effective in reducing suicide risk and deliberate self-harm in adult populations.Conclusions:Although CAMS appears to show promise in managing suicidal patients across a range of measures, further evidence is needed to clarify its efficacy in managing suicide risk and deliberate self-harm.
... Patients were randomized to CAMS or TAU from two ambulatory acute outpatient units, three inpatient units and two regular outpatient units at Division of Mental health and addiction, Vestre Viken hospital trust, Norway. The study protocol has previously been published (Ryberg et al., 2016). The study was approved by the Regional Committees for Medical and Health Research Ethics, Region South-East, Norway, 2014/465. ...
... Excluded were patients who were; unable to provide an informed consent (e.g., due to intellectual disability or dementia, active hallucinations), had poor Norwegian language acquisition, diagnosed with a developmental disorder (e.g. Asperger syndrome or Autism) or previously been exposed to CAMS treatment components (Ryberg et al., 2016). Altogether 43 therapists participated in the trial. ...
... TAU was an active intervention of high-quality standard care (Ryberg et al., 2016). The TAU intervention was represented by the diversity of orientations practiced within specialized care in Norway today. ...
... Recommendation 4: Suicide-specific psychosocial interventions for people with a history of self-harm Rationale and literature review In addition to the treatment of the mental health problems and addiction, there is emerging evidence suggesting that suicide-specific psychological treatments such as problem solving therapy, dialectical behaviour therapy (DBT), 38 cognitive behavioural therapy for suicidal behaviour (CBT-suicidal behaviour), 39 interpersonal therapy, 40 and brief psychological treatments 17 after self-harm (e.g., Collaborative Assessment and Management of Suicidality [CAMS]) 41 are effective in reducing suicide attempts. The CAF should consider conducting a needs assessment for training for clinicians interested in providing psychological interventions in the post selfharm period. ...
... 39 More recently, the CAMS suicide prevention protocol has also been found to decrease suicidal ideation and overall symptom distress, while at the same time increasing feelings of hope. 41 DBT has advantages in that it has been more widely disseminated than any other suicide prevention outpatient treatment and is well described in published manuals. However, DBT is a complex, multi-session treatment that lasts for 6-12 months and is best delivered by members of a team who have received DBT training together. ...
Introduction: An Expert Panel on suicide prevention convened October 23–26, 2016 to review current practices and recommend suicide prevention strategies for the Canadian Forces Health Services (CFHS). It included subject matter experts from Canada, the United States, and the United Kingdom, and representatives from Veterans Affairs Canada (VAC). Methods: We reviewed evidence and best practices for suicide prevention in civilian and military populations as well as the components of the CFHS mental health services and suicide prevention programs, and compared them to current evidence-informed best practices. We suggested improvements for CFHS mental health services and suicide prevention programs, and areas of future inquiry to improve suicide prevention. Results: Over the past 10 years there have been an average 16.6 suicide deaths annually among Canadian Armed Forces (CAF) regular force and primary reserves combined. Available mental health services for serving military personnel with suicidal behaviour exceed that for the Canadian civilian population. We identified many factors associated with suicidal behaviour, but acknowledged that it is extremely difficult to predict at an individual level. We agreed that the goal is to have no suicides in the CAF regular force population, but that not all suicides are preventable. We made 11 suggestions to improve suicide prevention in the CFHS. Discussion: The CFHS provides the highest quality mental health care for military personnel. Our recommendations are based on state-of-the-art research evidence, and their implementation will ensure that the CFHS leads the way in providing outstanding care for military personnel dealing with suicidal behaviour.
... 300 Efforts have also been made to establish whether the Collaborative Assessment and Management of Suicidal ideation and behaviour (CAMS) is feasible and clinically effective. 301 The Attempted Suicide Short Intervention Program (ASSIP), a brief intervention consisting of integrated therapy and personalised letters, showed encouraging findings in patients who have attempted suicide. 302 A meta-analysis 303 of therapeutic interventions for attempted suicide and self-harm in adolescents found that therapeutic interventions are effective in reducing self-harm when it is treated as a global category that includes suicidal and non-suicidal self-harm, but that the effects are weaker when suicidal and non-suicidal behaviour are examined separately. ...
Background: Psychological treatments occupy an important place in evidence-based mental health treatments. Now is an exciting time to fuel treatment research: a pressing demand for improvements is poised alongside new opportunities from closer links with sister scientific and clinical disciplines. The need to improve mental health treatment is great; even the best treatments do not work for everyone, treatments have not been developed for many mental disorders, and the implementation of treatments needs to address worldwide scalability. Psychological treatments have yet to benefit from numerous innovations that have occurred in science, particularly those that have emerged in the past 20 years, and arguably vice versa. This Commission comprises ten parts that each outline an area in which we see substantial opportunity and scope for advancements that will move psychological treatments research forward. / Part 1: How do existing treatments work? Making the case for the mechanisms of psychological treatments Beyond knowing that an intervention is efficacious, research initiatives are needed that clarify the key mechanisms through which interventions work. An experimental psychopathological approach enables the identification of mechanisms. Research on these mechanisms has considerable scope to facilitate treatment innovation. / Part 2: Where can psychological treatments be deployed? Research to improve mental health worldwide We outline a number of factors to facilitate worldwide access to psychological treatments. Future research initiatives need to continue to develop and assess the efficacy of brief and flexible interventions that can be adapted to meet the needs of individuals across cultural contexts, and delivered and disseminated in a sustainable way. / Part 3: With what? The potential for synergistic treatment effects—using and developing cross-modal treatment approaches The combination of psychological and pharmacological treatments needs to be better understood, both in terms of the clinical effect and the underlying shared and different mechanisms. Efforts to develop and investigate the efficacy of novel cross-modal treatments could contribute to treatment innovation. / Part 4: When in life? Psychological science, prevention, and early intervention—getting the approach right from the start The social and economic tolls of mental health problems early in life make the development of effective prevention and early intervention approaches a priority. A preventive focus and a developmental approach are needed to identify risk factors for psychopathology, and identification of the optimal time at which to offer prevention approaches is needed to increase the likelihood of vulnerable young people growing up with positive mental health. / Part 5: Technology—can we transform the availability and efficacy of psychological treatment through new technologies? New technologies provide exciting and timely means by which to disseminate and extend the efficacy and global reach of evidence-based interventions. eHealth and mHealth approaches that use information technology (eg, the internet, virtual reality, serious gaming) and mobile and wireless applications (eg, text messaging, apps) are examples of how technology has been harnessed to innovate psychological treatments and their availability and evaluation. / Part 6: Trials to assess psychological treatments The findings of randomised controlled trials that assess psychological therapies inform policy and practice. Accordingly, the design and conduct of these trials warrants scrutiny and ongoing efforts for quality improvement (eg, reporting standards, specification of protocols, inclusion and exclusion criteria, choice of outcome measures, measurement of adverse effects, and prevention of bias in design and analysis). We outline several opportunities for further improvement that should enhance the credibility and quality of future trials. / Part 7: Training—can we cultivate a vision for interdisciplinary training across mental health sciences to improve psychological treatments? Early examples of collaboration between basic scientists and clinicians translated into historical steps in the innovation of psychological treatment. Such synergy has become less apparent in the past few years. The improvement in links between clinical psychology, psychiatry, and basic research has the potential to deliver more advances in psychological treatments. We propose opportunities to improve training in interdisciplinary mental health sciences. This training approach would be the first step toward forging links between scientists and clinicians in the next generation and bridging the gap between clinical practice and the basic research programmes that underpin psychological treatments. / Part 8: Whom should we treat, for what, and with what? Embracing the complexity of mental disorders from personalised models to universal approaches Mental disorders are inherently complex (eg, hetero-geneity in symptoms across disorders, high rates of comorbidity) and evidence-based treatments must address this complexity. Potential solutions include considering both highly individualised (ie, personalised) approaches and so-called universal or transdiagnostic approaches that target common mechanisms. A goal of future research will be to examine whether these approaches improve treatment effectiveness. / Part 9: Target: suicidal behaviour—protecting lives Suicidal behaviour is one of many areas in which advances are needed. Despite developments in the understanding of risk factors that predict the likelihood of suicide attempts, and the treatment and prevention of suicidal behaviour, many questions remain. We specify areas for future research—eg, use of new technologies, the role of culture, input from individuals with lived experience of suicidal behaviour, and using a team-based approach in the development, assessment, and dissem-ination of prevention efforts. / Part 10: Active innovation and scrutiny of future psychological treatments research The task of improving psychological treatments is an exciting prospect for scientists and clinicians with an interest in the so-called science of mental life. Clinicians, researchers, service users, carers, funders, commissioners, managers, policy planners, and change experts all have a part to play in improving psychological treatment. Some long-held ideas need examination, from the branding of psychological treatment types, to considering what people actually want treatment for. Scrutiny of new ideas should be rigorous and yet encourage innovation.
... Towards this end, our findings support the in-depth assessment of suicidal ideation since it de facto is associated with subsequent suicide. Ways to do this are available, such as by using the Suicide Status Form (SSF) where suicide specific issues are addressed in detail in a collaborative manner between the patient and clinician [33][34][35][36]. ...
Objective
No prior study appears to have focused on predictors of suicide in the general patient population admitted to psychiatric acute wards. We used a case-control design to investigate the association between suicide risk factors assessed systematically at admission to a locked-door psychiatric acute ward in Norway and subsequent death by suicide.
Method
From 2008 to 2013, patients were routinely assessed for suicide risk upon admission to the acute ward with a 17-item check list based on recommendations from the Norwegian Directorate of Health and Social Affairs. Among 1976 patients admitted to the ward, 40 patients, 22 men and 18 women, completed suicide within December 2014.
Results
Compared to a matched control group (n = 120), after correction for multiple tests, suicide completers scored significantly higher on two items on the check list: presence of suicidal thoughts and wishing to be dead. An additional four items were significant in non-corrected tests: previous suicide attempts, continuity of suicidal thoughts, having a suicide plan, and feelings of hopelessness, indifference, and/or aggression. A brief scale based on these six items was the only variable associated with suicide in multivariate regression analysis, but its predictive value was poor.
Conclusion
Suicide specific ideations may be the most central risk markers for suicide in the general patient population admitted to psychiatric acute wards. However, a low predictive value may question the utility of assessing suicide risk.
Following a suicide attempt, components of aftercare can include efforts to reduce suicidal behavior (i.e., suicide, attempt, or ideation) of a person who has attempted suicide and facilitate the psychosocial adjustment of the patient and their family members. The purpose of this systematic review and meta-analysis of key outcomes was to synthesize the existing evidence on interventions for people who have attempted suicide and their family members.
The authors found that aftercare interventions show a statistically significant reduction in further suicide attempts for intervention participants. Studies also reported a reduction in suicide deaths, depression, and hopelessness, but the results are based on limited quality of evidence. The uptake of interventions and treatment retention varied widely by aftercare intervention. The authors could not explore the effects of the intervention target (e.g., participants who attempted suicide versus family members or both) or populations because of the homogeneity of the sample and the lack of studies measuring family member responses. The identified studies did not meaningfully address the effects of interventions on family members because these were rarely included in existing research studies.
Background: Self‐harm (SH; intentional self‐poisoning or self‐injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.
Objectives: To assess the effects of psychosocial interventions for self‐harm (SH) compared to comparison types of care (e.g. treatment‐as‐usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.
Search methods: We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).
Selection criteria: We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment‐as‐usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow‐up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.
Data collection and analysis: We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post‐intervention) was appraised for each intervention using the GRADE approach.
Main results: We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)‐based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow‐up time points (e.g., 6‐ and 12‐months) there was some evidence that individual CBT‐based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post‐intervention assessment. On the basis of data from a single trial, mentalisation‐based therapy (MBT) reduces repetition of SH and frequency of SH by the post‐intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high‐certainty evidence). A group‐based emotion‐regulation psychotherapy may also reduce repetition of SH by the post‐intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate‐certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group‐based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At‐Risk Territories (START) and the SUicide‐PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE‐MISS) models, have any effect on repetition of SH by the post‐intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department‐based interventions.
Authors' conclusions: Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow‐up time points, although no such effect was found at the post‐intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group‐based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
Background
Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers‐Winterling 2012).
Objectives
To assess the beneficial and harmful effects of psychological therapies for people with BPD.
Search methods
In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.
Selection criteria
Randomised controlled trials comparing different psychotherapeutic interventions with treatment‐as‐usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.
Data collection and analysis
At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.
Main results
We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation‐based treatment (MBT). The comparator interventions included treatment‐as‐usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months.
Psychotherapy versus TAU
Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) −0.52, 95% confidence interval (CI) −0.70 to −0.33; 22 trials, 1244 participants; moderate‐quality evidence. This corresponds to a mean difference (MD) of −3.6 (95% CI −4.4 to −2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is −3.0 points).
Psychotherapy may be more effective at reducing self‐harm compared to TAU (SMD −0.32, 95% CI −0.49 to −0.14; 13 trials, 616 participants; low‐quality evidence), corresponding to a MD of −0.82 (95% CI −1.25 to 0.35) on the Deliberate Self‐Harm Inventory Scale (range 0 to 34). The MIREDIF of −1.25 points was not reached.
Suicide‐related outcomes improved compared to TAU (SMD −0.34, 95% CI −0.57 to −0.11; 13 trials, 666 participants; low‐quality evidence), corresponding to a MD of −0.11 (95% CI −0.19 to −0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of −0.17 points was not reached.
Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD −0.45, 95% CI −0.68 to −0.22; 22 trials, 1314 participants; low‐quality evidence), corresponding to a MD of −2.8 (95% CI −4.25 to −1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of −4.0 points was not reached.
Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases.
A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning.
Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD −0.39, 95% CI −0.61 to −0.17; 22 trials, 1568 participants; very low‐quality evidence), corresponding to a MD of −2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of −3.0 points was not reached.
BPD‐specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data.
Psychotherapy versus waiting list or no treatment
Greater improvements in BPD symptom severity (SMD −0.49, 95% CI −0.93 to −0.05; 3 trials, 161 participants), psychosocial functioning (SMD −0.56, 95% CI −1.01 to −0.11; 5 trials, 219 participants), and depression (SMD −1.28, 95% CI −2.21 to −0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low‐quality evidence). No evidence of a difference was found for self‐harm and suicide‐related outcomes.
Individual treatment approaches
DBT and MBT have the highest numbers of primary trials, with DBT as subject of one‐third of all included trials, followed by MBT with seven RCTs.
Compared to TAU, DBT was more effective at reducing BPD severity (SMD −0.60, 95% CI −1.05 to −0.14; 3 trials, 149 participants), self‐harm (SMD −0.28, 95% CI −0.48 to −0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD −0.36, 95% CI −0.69 to −0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self‐harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD −0.58, 95% CI −1.22 to 0.05, 4 trials, 333 participants). All findings are based on low‐quality evidence. For secondary outcomes see review text.
Authors' conclusions
Our assessments showed beneficial effects on all primary outcomes in favour of BPD‐tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF‐defined cut‐off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) .
The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low‐quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self‐harm and suicide‐related outcomes.
However, compared to TAU, we observed effects in favour of DBT for BPD severity, self‐harm and psychosocial functioning and, for MBT, on self‐harm and suicidality at end of treatment, but these were all based on low‐quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
In a randomized controlled trial, we found that suicidal patients who received Collaborative Assessment and Management of Suicidality (CAMS) reported greater improvements in suicidal ideation and mental health distress compared to participants who received Treatment As Usual (TAU). Here, we explored moderators and mediators of the effectiveness of CAMS. Compared to TAU, CAMS was more effective in reducing suicidal ideation when the working alliance, in particular its bond subcomponent, was low. In terms of reducing mental health distress, CAMS was superior to TAU only for participants who did not use illicit drugs, and more tentatively, only for patients without borderline personality traits. We suggest that CAMS may repair a difficult vantage point in terms of poor working alliance in patients with suicide ideation. To obtain superior benefits of CAMS upon more general mental health distress in patients with drug abuse or borderline traits, these problems may need to be more explicitly targeted in parallel.
