Accepted Manuscript

Is psychotherapy effective for reducing suicide attempt and non-suicidal self-injury

rates? Meta-analysis and meta-regression of literature data

Raffaella Calati, Philippe Courtet

PII: S0022-3956(16)30066-8
DOI: 10.1016/j.jpsychires.2016.04.003
Reference: PIAT 2850

To appear in: Journal of Psychiatric Research

Received Date: 6 January 2016

Revised Date: 13 April 2016
Accepted Date: 14 April 2016

Please cite this article as: Calati R, Courtet P, Is psychotherapy effective for reducing suicide attempt
and non-suicidal self-injury rates? Meta-analysis and meta-regression of literature data, Journal of
Psychiatric Research (2016), doi: 10.1016/j.jpsychires.2016.04.003.

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 ACCEPTED MANUSCRIPT
IS PSYCHOTHERAPY EFFECTIVE FOR REDUCING SUICIDE ATTEMPT AND NON-

SUICIDAL SELF-INJURY RATES?

META-ANALYSIS AND META-REGRESSION OF LITERATURE DATA

Raffaella Calati, Psy.D., Ph.D.a, b, Philippe Courtet, MD, Ph.D.a, b, c

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INSERM U1061, University of Montpellier UM1, Montpellier, France

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FondaMental Foundation, France

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Department of Emergency Psychiatry & Acute Care, Lapeyronie Hospital, CHU
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Montpellier, Montpellier, France
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Running title: psychotherapy and suicide attempts.

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To whom correspondence should be addressed:

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Raffaella Calati, Psy.D. Ph.D.

INSERM U1061

University of Montpellier UM1, Montpellier, France

E-mail: raffaella.calati@gmail.com

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Abstract

Objective: To determine the efficacy of psychotherapy interventions for reducing suicidal

attempts (SA) and non-suicidal self-injury (NSSI).

Methods: Meta-analysis of randomized controlled trials (RCTs) comparing psychotherapy

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interventions and treatment as usual (TAU; including also enhanced usual care, psychotropic

treatment alone, cognitive remediation, short-term problem-oriented approach, supportive

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relationship treatment, community treatment by non-behavioral psychotherapy experts,

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emergency care enhanced by provider education, no treatment) for SA/NSSI. RCTs were

extracted from MEDLINE, EMBASE, PsycINFO and Cochrane Library and analyzed using

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the Cochrane Collaboration Review Manager Software and Comprehensive Meta-analysis.
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Results: In the 32 included RCTs, 4114 patients were randomly assigned to receive
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psychotherapy (n=2106) or TAU (n=2008). Patients who received psychotherapy were less

likely to attempt suicide during the follow-up. The pooled risk difference for SA was -0.08
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(95% confidence intervals=-0.04 to -0.11). The absolute risk reduction was 6.59%
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(psychotherapy: 9.12%; TAU: 15.71%), yielding an estimated number needed to treat of 15.

Sensitivity analyses showed that psychotherapy was effective for SA mainly in adults,
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outpatients, patients with borderline personality disorder, previously and non-previously

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suicidal patients (heterogeneous variable that included past history of SA, NSSI, deliberate
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self-harm, imminent suicidal risk or suicidal ideation), long- and short-term therapies, TAU

only as a control condition, and mentalization-based treatment (MBT). No evidence of

efficacy was found for NSSI, with the exception of MBT. Between-study heterogeneity and

publication bias were detected. In the presence of publication bias, the Duval and Tweedie’s

“trim and fill” method was applied.

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Conclusion: Psychotherapy seems to be effective for SA treatment. However, trials with

lower risk of bias, more homogeneous outcome measures and longer follow-up are needed.

Key words: psychotherapy, suicide attempt, personality disorder.

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INTRODUCTION

In 2012, an estimated 804.000 suicide deaths (SD) occurred worldwide, corresponding to an

annual suicide rate of 11.4 per 100.000 people (World Health Organization, 2014). Moreover,

for each adult SD there may have been more than 20 suicide attempters. Significantly, in the

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general population a prior suicidal attempt (SA) is the most important risk factor for suicide.

The inclusion of suicidal behavior disorder in the fifth edition of the Diagnostic and Statistical

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Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013) highlights

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the need of additional studies to identify effective strategies for its prevention and treatment.

However, one problem in research on suicide is the confusion resulting from the use of

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different terms to define suicidal behavior (De Leo et al., 2006). Indeed, in the United States,
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SA (self-harm with an intention to die) is distinguished from non-suicidal self-injury (NSSI;

self-harm without intention to die). In the United Kingdom, and more generally in Europe,
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and in South Africa, Australia and New Zealand, deliberate self-harm (DSH; without focus on
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the intent) is commonly used. It includes self-harm with suicidal intent, NSSI and self-harm
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episodes with unclear intent. However, DSH has been criticized because it is too broad

(Linehan, 1997). Most studies on adolescents focused on DSH (Ougrin et al., 2012, Ougrin
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and Boege, 2013), and DSH and NSSI prevalence in adolescents from different countries are

similar (Muehlenkamp et al., 2012). Moreover, a meta-analysis of the overall international

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NSSI prevalence reported that the pooled NSSI prevalence was 17.2% among adolescents,
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13.4% among young adults and 5.5% among adults (Swannell et al., 2014).

Very few evidence is available on the usefulness of specific pharmacological interventions for

suicidal behavior (Hawton et al., 2015a), with the exception of the recent enthusiasm for

ketamine (Bolton et al., 2015). Similarly, consensus is lacking on the effectiveness of

psychological interventions for suicidal behavior. It has been reported that a wide range of

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therapies, such as cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT)

and problem-solving approaches, are effective in reducing suicidal thoughts and behaviors,

when they are considered as part of an extremely wide outcome variable that includes

different indicators, such as SA, suicidal plans, suicidal thoughts together with hopelessness

and satisfaction with life measures (Tarrier et al., 2008). Conversely, psychosocial

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interventions after DSH do not seem to reduce the likelihood of subsequent SD (Crawford et

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al., 2007). Moreover, a recent review of randomized controlled trials (RCTs) on psychosocial

interventions for DSH in children and adolescents found very little evidence supporting the

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effectiveness of such approaches in these populations (Hawton et al., 2015b). This lack of

consensus could be explained by the high between-study heterogeneity due to the difference

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in suicidal phenotypes (suicidal ideation, NSSI, SA, DSH, SD), treatments, diagnosis
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[borderline personality disorder (BPD), major depressive disorder, bipolar disorder,
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schizophrenia, anorexia and anxiety disorders] and populations (adults, adolescents) included

in these RCTs.
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A recent meta-analysis evaluated the efficacy of specific therapeutic (psychological, social

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and pharmacological) interventions in reducing any type of DSH (SA, NSSI and/or self-harm
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with ambiguous intent) (19 included studies) and SA alone (8 included studies) in

adolescents. Evidence of treatment efficacy was only found for the global category of DSH,
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with high between-study heterogeneity, but not for SA (Ougrin et al., 2015). Therefore, we
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decided to perform a new meta-analysis to extend the analysis on the efficacy of therapeutic

interventions also to adults and to focus only on SA and NSSI outcomes. To this aim, in the

present meta-analysis, we primarily evaluated the efficacy of psychotherapeutic interventions

(compared with treatment as usual) on the SA outcome in different populations with different

diagnoses. We also evaluated the efficacy of psychotherapeutic interventions for the treatment

of NSSI/self-harming/self-mutilating behaviors (secondary outcome). Indeed, although there

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is a considerable overlap between SA and NSSI, the factors contributing to these two

conditions could be slightly different (Dougherty et al., 2009). Finally, we also performed

sensitivity and meta-regression analyses to take into account the possible between-study

heterogeneity. To our knowledge this is the first meta-analysis that evaluated the efficacy of

psychotherapies in specifically reducing SA and NSSI rates in both adults and adolescents.

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METHODS

This meta-analysis was performed according the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses Statement (PRISMA) (Moher et al., 2009).

Search strategy and selection criteria

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Records were primarily identified by a MEDLINE-based search, but results obtained by

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interrogating EMBASE, PsycINFO, and the Cochrane Library (until June 2015) databases

were also incorporated. The following search terms were used: (psychotherapy OR

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psychosocial OR acceptance and commitment therapy OR cognitive behavio(u)ral therapy

OR cognitive remediation OR cognitive therapy OR dialectical behavio(u)r therapy OR

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interpersonal psychotherapy OR mentalization-based treatment OR mindfulness based
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cognitive therapy OR problem solving therapy OR schema-focused therapy OR transference-
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focused psychotherapy) AND (suicid* OR self(-)harm OR non-suicidal self-injury OR self-

mutilation). The reference lists of the identified studies, reviews and meta-analyses were also
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examined to extract additional articles.

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Studies were included if: they were published in a peer-reviewed journal; they were written in
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English; they were RCTs; they compared a form of psychotherapy (or a substantial

component of psychotherapeutic methods in the treatment) with treatment as usual (TAU) that
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included also enhanced usual care (such as a facilitated referral process with ongoing clinical
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monitoring), psychotropic treatment alone, cognitive remediation, short-term problem-

oriented approach, supportive relationship treatment, community treatment by non-behavioral

psychotherapy experts, usual emergency care enhanced by provider education, no treatment;

they reported SA and/or NSSI as outcome measures. RCTs that compared psychotherapy (or

combined therapy) with antidepressants were included. In this case, data on psychotherapy

alone and in combination were pooled and compared with the data on antidepressants. When

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more than two groups were present, only the psychotherapy and control groups were selected

(e.g., (Wei et al., 2013)), or samples were pooled (e.g., (Brent et al., 2009)). Trials that

evaluated long-term or short-term psychotherapeutic treatments were included. Short-term

treatment was arbitrarily defined as a treatment with a maximum duration of 3 months or with

a maximum of 14 sessions.

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Studies were excluded if: they were performed on overlapping samples; they focused on an

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intervention that did not involve patients, but only their carers (e.g., Youth-Nominated

Support Team (King et al., 2009)); they considered SA and NSSI/self-harming behaviors

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together; they did not report SA in both groups (Rucci et al., 2011, Walkup et al., 2008,

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Weinberg et al., 2006) because in this case it was not possible to calculate the overall effect
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size (Sweeting et al., 2004).

Outcomes
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The primary outcome was the SA rate. SA occurrence (at least one) during the treatment
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and/or follow-up period was extracted for each sample. When both SA and SD rates were
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indicated, the total (SA + SD) rate was included (Hawton et al., 1987, Hollon et al., 1992).
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The secondary outcome was the NSSI/self-harming/self-mutilating behavior rate. NSSI

definition included self-injuries (most commonly, cutting or burning) without suicidal intent.
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Self-harming and self-mutilating behaviors were considered together with NSSI only when
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their rates were presented separately from the SA rates. For example, in the two studies by

Bateman et al. (Bateman and Fonagy, 1999, Bateman and Fonagy, 2009), the criteria for

“self-mutilation” were as follows: “1) deliberate, 2) resulted in visible tissue damage and 3)

nursing or medical intervention required”. These criteria are different from the NSSI criteria;

however, in our meta-analysis NSSI and self-mutilation were considered together because in

the two mentioned studies self-mutilation acts were distinguished from SA.

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When the outcomes of interest were not reported in the selected RCTs, the authors were

directly contacted.

Data extraction and quality assessment

Data were screened by two reviewers (R.C. and P.C.); disagreements were solved by

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discussion. For each RCT, the evaluated treatments, total sample size, percentage of females,

mean age, diagnosis, assessment of medications, duration of psychotherapeutic treatment,

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number of weekly sessions, duration of the follow up, main scales used for the assessment,

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and main results were identified (see Table 1). The quality of reporting and the risk of bias for

the included studies were assessed with the Jadad scale (Jadad et al., 1996) and also the

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Cochrane Risk of Bias Tool (Higgins and Green, 2011). The Jadad scores were used to
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perform a meta-regression, while the Cochrane Risk of Bias Tool was employed because it

allows a risk of bias evaluation of each study simply by visual inspection of a risk of bias
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summary table (Figs. 2 and 3, and Figs. 1S and 2S of the Supplementary materials). As the
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retained RCTs were only single-blind trials (due to the study type), double-blind was not
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included as a criterion. Moreover, for each study, the reported reliability estimates (kappa and

intra-class correlation coefficients - ICC) were assessed (Supplementary Table 1S).

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Data analysis
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Intention-to-treat (ITT) data were included when possible, otherwise completers’ data were
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considered. To perform the meta-analyses, data were entered in and analyzed with the

Cochrane Collaboration Review Manager Software (RevMan, version 5.3). Individual and

pooled risk differences and associated 95% confidence intervals (CI) were calculated.

Between-study heterogeneity was assessed with the Chi2 goodness of fit and I2 tests. The

significance of the pooled effect size was determined using a Z test. Data were analyzed using

a random effect framework due to the assumption of between-study heterogeneity. However,

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using a fixed effect framework, results did not consistently change (data available on request).

A funnel plot was created to reveal the preferential publication of statistically significant

results. The Egger’s test was also used to evaluate the funnel plot asymmetry (Egger et al.,

1997) with the STATISTICA software (StatSoft, 1995). In the presence of publication bias,

the Duval and Tweedie’s “trim and fill” method (Duval and Tweedie, 2000) was applied

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using Comprehensive Meta-analysis (version 2.2) to adjust the effect size and CIs for the

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missing studies and they were then assumed to be unbiased. Post hoc sensitivity and meta-

regression analyses were performed to account for between-study heterogeneity. For the

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sensitivity analyses, the following subgroups of particular interest (≥2 RCTs) were

considered: adults, adolescents, outpatients, inpatients, patients with BPD, patients with

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depression, patients with schizophrenia-spectrum disorders, previously and non-previously
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suicidal patients (heterogeneous variable comprising previous SA, NSSI, DSH, imminent
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suicidal risk or suicidal ideation), long- and short-term psychotherapies, TAU only as a

control condition, CBT, DBT, cognitive therapy (CT), mentalization-based treatment (MBT),
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interpersonal psychotherapy (IPT) and NSSI (strictly defined). Concerning the influence of
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different potential moderators (meta-regressors) on both outcomes, the following variables

were considered: quality of the studies (Jadad scale), gender (female) and mean age of the
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included patients, number of weekly sessions, total number of sessions, psychotherapy

duration (years) and follow-up duration (years). For meta-regression analyses, data were
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evaluated using Comprehensive Meta-analysis (version 2.2). All p values were two-tailed and

statistical significance was set at the 0.05 level.

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RESULTS

Included trials

Among the 6961 references initially retrieved, 5001 remained after duplicate elimination.

After a first selection, 160 full-text articles were assessed for eligibility and after careful

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reading, 32 RCTs were retained for the analysis (Asarnow et al., 2011, Bateman and Fonagy,

1999, Bateman and Fonagy, 2009, Brent et al., 2009, Brown et al., 2005, Comtois et al., 2011,

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Davidson et al., 2006, Diamond et al., 2010, Donaldson et al., 2005, Esposito-Smythers et al.,

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2011, Guthrie et al., 2001, Hawton et al., 1987, Hollon et al., 1992, Hvid et al., 2011,

Klingberg et al., 2012, Kuipers et al., 1997, Linehan et al., 1991, Linehan et al., 2006,

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McLeavey et al., 1994, McMain et al., 2009, Morley et al., 2014, Mufson et al., 2004,
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Nordentoft et al., 2002, Pistorello et al., 2012, Rudd et al., 2015, Salkovskis et al., 1990, Tyrer

et al., 2003, van der Sande et al., 1997, Verheul et al., 2003, Vitiello et al., 2009, Wei et al.,
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2013, Wong, 2008) (see flowchart in Figure 1 and summary in Table 1).
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The retained RCTs focused on adults (n=25, 78.1%) and adolescents (n=7, 21.9%) (studies on
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adolescents: (Asarnow et al., 2011, Brent et al., 2009, Diamond et al., 2010, Donaldson et al.,

2005, Esposito-Smythers et al., 2011, Mufson et al., 2004, Vitiello et al., 2009)). They
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included patients with different diagnoses: BPD (n=8, 25%) (Bateman and Fonagy, 1999,
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Bateman and Fonagy, 2009, Davidson et al., 2006, Linehan et al., 1991, Linehan et al., 2006,
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McMain et al., 2009, Pistorello et al., 2012, Verheul et al., 2003), depression (n=6, 18.7%)

(Brent et al., 2009, Brown et al., 2005, Hollon et al., 1992, Mufson et al., 2004, Vitiello et al.,

2009, Wong, 2008), schizophrenia-spectrum disorders (n=3, 9.4%) (Klingberg et al., 2012,

Kuipers et al., 1997, Nordentoft et al., 2002), and previous “suicidality” (past history of SA,

NSSI, DSH, imminent suicidal risk or suicidal ideation) (n=14, 43.7%) (Asarnow et al., 2011,

Comtois et al., 2011, Donaldson et al., 2005, Esposito-Smythers et al., 2011, Guthrie et al.,

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2001, Hawton et al., 1987, Linehan et al., 2006, McLeavey et al., 1994, McMain et al., 2009,

Pistorello et al., 2012, Salkovskis et al., 1990, Tyrer et al., 2003, van der Sande et al., 1997,

Wei et al., 2013). These RCTs evaluated the effects of long-term (n=15, 46.9%) and short-

term psychotherapies (n=17, 53.1%) (trials on short-term psychotherapies: (Asarnow et al.,

2011, Brent et al., 2009, Brown et al., 2005, Comtois et al., 2011, Diamond et al., 2010,

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Donaldson et al., 2005, Guthrie et al., 2001, Hawton et al., 1987, Hollon et al., 1992,

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McLeavey et al., 1994, Mufson et al., 2004, Rudd et al., 2015, Salkovskis et al., 1990, Tyrer

et al., 2003, van der Sande et al., 1997, Wei et al., 2013, Wong, 2008). The most represented

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psychotherapeutic treatments were: CBT (n=13, 40.6%) (Asarnow et al., 2011, Brent et al.,

2009, Davidson et al., 2006, Donaldson et al., 2005, Esposito-Smythers et al., 2011,

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Klingberg et al., 2012, Kuipers et al., 1997, Morley et al., 2014, Rudd et al., 2015, Salkovskis
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et al., 1990, Tyrer et al., 2003, Vitiello et al., 2009, Wong, 2008), DBT (n=5, 15.6%)
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(Linehan et al., 1991, Linehan et al., 2006, McMain et al., 2009, Pistorello et al., 2012,

Verheul et al., 2003), CT (n=3, 9.4%) (Brown et al., 2005, Hollon et al., 1992, Wei et al.,
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2013), psychoanalytically-oriented partial hospitalization or MBT (n=2, 6.2%) (Bateman and

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Fonagy, 1999, Bateman and Fonagy, 2009) and IPT (n=2, 6.2%) (Guthrie et al., 2001, Mufson

et al., 2004). In total, 4114 patients were randomly assigned to receive a psychotherapeutic
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treatment (n=2106) or TAU (n=2008).

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Primary outcome: suicide attempt rate

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Thirty-one trials reported the occurrence of one or more SA (Figure 2) (Asarnow et al., 2011,

Bateman and Fonagy, 1999, Bateman and Fonagy, 2009, Brown et al., 2005, Comtois et al.,

2011, Davidson et al., 2006, Diamond et al., 2010, Donaldson et al., 2005, Esposito-Smythers

et al., 2011, Guthrie et al., 2001, Hawton et al., 1987, Hollon et al., 1992, Hvid et al., 2011,

Klingberg et al., 2012, Kuipers et al., 1997, Linehan et al., 1991, Linehan et al., 2006,

McLeavey et al., 1994, McMain et al., 2009, Morley et al., 2014, Mufson et al., 2004,

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Nordentoft et al., 2002, Pistorello et al., 2012, Rudd et al., 2015, Salkovskis et al., 1990, Tyrer

et al., 2003, van der Sande et al., 1997, Verheul et al., 2003, Vitiello et al., 2009, Wei et al.,

2013, Wong, 2008). Patients allocated to receive psychotherapy were less likely to attempt

suicide during the follow-up period in comparison with patients in the TAU arm (z=4.12,

p<0.0001). The pooled risk difference for SA was -0.08 (95% CI =-0.04 to -0.11). The pooled

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difference between the risk of SA in the psychotherapy arm (9.12%) and in the TAU arm

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(15.71%) gave an absolute risk reduction of 6.59%, corresponding to a number needed to treat

of 15 to prevent one SA. As high between-study heterogeneity was detected (χ2=125.82,

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d.f.=30, p<0.00001, I2=76%), post hoc sensitivity analyses were performed in subgroups of

particular interest (≥2 RCTs) (Table 2). Significant results were found for: adults (p<0.0001);

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outpatients (p=0.0001); patients with BPD (p=0.004); previously suicidal patients (p=0.02)
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(i.e., with a past history of SA, NSSI, DSH, imminent suicidal risk or suicidal ideation); non-
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previously suicidal patients (p=0.0009) (i.e., without a past history of SA, NSSI, DSH,

imminent suicidal risk or suicidal ideation); long-term psychotherapies (p=0.002); short-term

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psychotherapies (p=0.005); studies with TAU only as control condition (p=0.005) (i.e.,
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studies where TAU was the only control treatment without any of the other non-

psychotherapy treatments we pooled in the primary analysis); psychoanalytically-oriented

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partial hospitalization or MBT (p=0.03).

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In the meta-regression analyses, the Jadad score (p=0.01), gender (p=0.007) and number of
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weekly sessions (p=0.001) showed a plausible, moderating effect on the outcome (SA rate)

(Table 3). Particularly, high Jadad score, female gender and high number of psychotherapy

sessions per week were associated with significant SA risk reduction.

Secondary outcome: non-suicidal self-injury rate

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Eight trials reported the occurrence of NSSI/self-harming behaviors (Figure 3) (Bateman and

Fonagy, 1999, Bateman and Fonagy, 2009, Brent et al., 2009, Davidson et al., 2006, McMain

et al., 2009, Pistorello et al., 2012, Tyrer et al., 2003, Verheul et al., 2003). No difference in

the NSSI/self-harming behavior rate was found between patients in the psychotherapy arm

and those in the TAU arm during the follow-up period (z=0.98, p=0.33), with a high between-

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study heterogeneity (χ2=26.44, d.f.=7, p=0.0004, I2=74%). In post hoc sensitivity analyses,

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significant results were found only for psychoanalytically oriented partial hospitalization and

MBT (p=0.03).

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Funnel plots and quality assessment

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The funnel plots for the studies included in the two main analyses are shown in Figures 3S
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and 4S, respectively (Supplementary material). Visual inspection highlighted funnel plot

asymmetry for the studies focused on SA outcome and the Egger’s test was significant
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(p=0.001), indicating the presence of publication bias. An additional analysis to adjust for
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publication bias using the “trim and fill” method showed that the adjusted pooled risk
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difference for SA was -0.07 (95% CI=-0.04 to -0.10). Conversely, the Egger’s test was not

significant (p=0.17) for studies on NSSI/self-harming behavior outcome, with no evidence of

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publication bias.
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The risk of bias graph (Figure 1S) and the risk of bias summary (Figure 2S) as well as the
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Jadad total scores (Table 1) summarize the results of the analyses to highlight other bias

types. Specifically, there was a high rate of unclear risk of bias because of the lack of

information in the studies. Blinding was associated with the highest risk of bias, due to the

specific design of the retained RCTs. Conversely, sequence generation showed the lowest risk

of bias. Concerning the Jadad scale (quality of reporting), five (15.6%) studies obtained the

maximum score (5), eight (25%) received a score of 4, and twelve (37.5%) a score of 3,

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indicating that most of the included studies were of good quality (78.1%). Six (18.7%) studies

received a score of 2, and only one (3.2%) obtained 1.

For each trial the reliability estimates are shown in Supplementary Table 1S. Kappa was

reported in ten studies (31.2%) and ICC in seven studies (21.9%). Overall, reliability was

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good (κ=0.72–0.80) and very good (κ=0.81–1.00 or ICC=0.83–1.00).

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DISCUSSION

The primary aim of this meta-analysis was to evaluate the efficacy of psychotherapeutic

treatments on SA rate in adults and adolescents. Patients allocated to receive psychotherapy

(31 of the included studies) were less likely to attempt suicide during the follow-up period in

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comparison with patients allocated to receive TAU or a similar condition. This finding is in

agreement with the results of a Danish matched cohort study showing that the risk of repeated

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DSH and mortality was lower in patients who received psychosocial therapy after DSH

compared with people who did not (Erlangsen et al., 2015). The present result is encouraging;

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however, the between-study heterogeneity was important, consistently with the high number

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of heterogeneous variables: different populations (adults and adolescents), diagnoses,
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psychotherapeutic interventions and treatment duration. To account for this high

heterogeneity, we performed a number of post hoc sensitivity and meta-regression analyses.

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Sensitivity analyses highlighted some clinically meaningful results. First, psychotherapy was

effective in adults, but not in adolescents. This is consistent with very recent findings on SA
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in adolescents (Ougrin et al., 2015) (when SA outcome has been considered separately from
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DSH as a global category) and also in adults (Tarrier et al., 2008). Similarly, the analysis by
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Hawton and colleagues of 11 RCTs on psychosocial interventions for DSH in children and

adolescents (Hawton et al., 2015b) showed the paucity of evidence for effective interventions.
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These authors followed an extremely rigorous methodology by considering only studies on

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children and adolescents and by avoiding pooling them in most of the analyses. We used

another approach to give a very broad overview of all the studies on the efficacy of

psychotherapeutic treatments for SA in both adults and adolescents. Moreover, not all the

studies retained in the two previous meta-analyses (Ougrin et al., 2015, Hawton et al., 2015b)

could be included here because of different inclusion/exclusion criteria.

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Our analysis then shows that psychotherapy was effective in outpatients, but not in inpatients.

These results could be related to the severity of inpatients’ symptomatology. On the other

hand, inpatients could have better outcomes because they can receive more intensive

treatments.

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In addition, the efficacy of psychotherapy was not detected in completers. This result could be

explained by the small number of studies included in the sensitivity analysis (k=6). Moreover,

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a tendency toward association (p=0.07) should be underlined.

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Our analysis also shows that psychotherapy was effective in patients with BPD, but not in

patients with depression or schizophrenia-spectrum disorders. These results suggest that SA

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treatment in these specific populations (patients with depression or schizophrenia) requires
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the improvement of existing clinical strategies. Similarly, psychotherapy was effective in

patients with and also in those without past history of “suicidality”, considered as a
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heterogeneous variable comprising previous SA, NSSI, DSH or suicidal risk and/or suicidal
D

ideation. This is in contrast with a previous meta-analysis that reported the lack of
TE

psychotherapy efficacy in preventing SD in patients with a past DSH episode (Crawford et al.,

2007). However, it should be stressed that we focused on SA, and not on SD, and previous
EP

suicidality is not the same as previous DSH.

C

Furthermore, our study found that both long- and short-term psychotherapies were effective,
AC

with a slightly higher effect size for long-term psychotherapies, and a lower heterogeneity for

short-term treatments. Finally, psychoanalytically oriented partial hospitalization or MBT was

the only effective treatment. However, only two small-sized studies were included. Moreover,

one of these studies focused on partial hospitalization treatment and this could explain the

better SA outcome. Indeed, partial hospitalization treatments are more intensive and also the

suicide risk during treatment may be reduced because of the in-hospital treatment setting.

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 ACCEPTED MANUSCRIPT
Meta-regression analyses led to interesting findings as well, showing that intensive

psychotherapy (high number of sessions per week) was associated with SA risk reduction.

Therefore, psychotherapeutic approaches, especially intensive treatments, could be effective.

Unfortunately, studies on other forms of psychotherapy (e.g., transference-focused

PT
psychotherapy (Clarkin et al., 2001) and acceptance and commitment therapy (Ducasse et al.,

2014)) could not be included in the main analyses and it would be interesting to evaluate them

RI
in the future.

SC
The presence of publication bias related to the studies concerning the primary outcome

slightly moderates the enthusiasm for these results. We tried to correct this bias by imputing

U
the presence of missing studies to obtain an unbiased estimate. Nevertheless, this point
AN
highlights the need of additional studies. Furthermore, the benefits of psychotherapy were

much less important in large, independently funded trials than in smaller studies and for this
M

reason the present results should be considered with further caution. Independent replications
D

of the initial positive RCTs also could increase the confidence in the reported results. New
TE

studies should be performed not only by the people who developed a specific intervention, as

in the case of MBT, but also by independent investigators. Our secondary aim was to evaluate
EP

the efficacy of psychotherapeutic treatments for NSSI/self-harming/self-mutilating behavior.

For this analysis, we included only studies (n=8) that specifically distinguished self-
C

harming/self-mutilating behaviors from SA, with the aim of segregating a highly

AC

homogeneous, phenomenologically distinct clinical entity. We found no difference in the rate

of NSSI/self-harming behaviors between patients allocated to receive psychotherapy and

those who received TAU, with high between-study heterogeneity. This is consistent with

recent meta-analytical findings on adolescents (Ougrin et al., 2015), although qualitatively

contrasting results have been reported (Turner et al., 2014). As most of the included studies

focused on adults (only one RCT concerned adolescents), this result seems to be stable across

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 ACCEPTED MANUSCRIPT
different populations. Sensitivity analyses reported the specific efficacy only of

psychoanalytically oriented partial hospitalization or MBT, consistently with previous results

on adults.

As underlined by Ougrin et al. in the case of adolescents (Ougrin et al., 2015), this reported

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lack of efficacy may suggest that psychotherapeutic strategies targeting NSSI should focus on

different aspects then those targeting SA. Actually this lack of efficacy, with the exception of

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MBT, could be linked to the specific personality profile of NSSI patients, that make them less

likely to respond to psychotherapeutic approaches. Moreover, the fact that in our analysis

SC
patients with a history of SA and NSSI and patients with NSSI alone were probably pooled

U
should be taken into account together with the reported differences between these two groups
AN
(Perez et al., 2014). However, this represents a constant challenge because NSSI is a strong

predictor of a future SA (Victor and Klonsky, 2014).

M

Considering that the quality of the included RCTs might have influenced the present findings,
D

the design of future studies should be substantially improved. As suggested by Bateman and
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Fonagy concerning the assessment of a treatment for BPD (Bateman and Fonagy, 2009), “a

randomized design for assessing such a treatment must meet the following minimal criteria:
EP

1) a comparison group also receiving a manualized, structured treatment with equivalent

supervision; 2) delivery of both by professionals trained to similar levels; 3) statistical power

C

to detect relatively small differences; and 4) a representative sample of clinically referred

AC

patients with a confirmed diagnosis […] at high risk of suicide”.

Moreover, additional aspects should be considered: variables linked to the therapist (the use

of specific therapy manuals and/or supervision groups; duration of training and supervision;

years of post-training experience; specific training on suicide treatment) and to the

psychotherapy [treatments that specifically target suicidal phenotypes or not; association with

psychotropic drugs (pharmacological classes and dosages), concurrently or sequentially;

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 ACCEPTED MANUSCRIPT
concomitant use of other therapeutic treatments (self-help groups, family or couple therapy,

psycho-educational groups)].

The main strong points of this meta-analysis are its large sample size (4114 patients) and the

fact that it is, to our knowledge, the first evaluation of the effectiveness of psychotherapies for

PT
reducing specifically SA and NSSI rates in both adults and adolescents. However, a major

limitation is that extremely different studies were pooled together. Therefore, we suggest that

RI
the reported results should be considered as a starting point for methodologically accurate

investigations. Moreover, we decided not to perform the Bonferroni correction for all the

SC
sensitivity analyses and we did not exclude the outliers (results available on request). Indeed,

U
after the Bonferroni correction (p≤0.0016), only some results on SA would have remained:
AN
the efficacy on adults, outpatients and non-previous suicidal patients. Moreover, after the

exclusion of outliers (including standardized residuals), we could not have shown the results
M

on MBT because the two studies by Bateman et al. were outliers (Bateman and Fonagy, 1999,

Bateman and Fonagy, 2009). We followed this approach to preserve results that, in our
D

opinion, were clinically interesting.

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A number of further limitations should be listed: 1) the between-study heterogeneity and the
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presence of publication bias; 2) the small sample size of the NSSI meta-analysis. This could

represent a possible explanation for the reported lack of efficacy of psychotherapeutic

C

treatments in NSSI. Moreover, considering the low number of included trials (n<10)
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concerning NSSI, the presence of a publication bias cannot be totally excluded; 3) publication

bias is only one of the possible causes of funnel plot asymmetry for the study on SA; 4) most

of the included studies concerned small patient populations (e.g., (Salkovskis et al., 1990,

Donaldson et al., 2005, Esposito-Smythers et al., 2011, Comtois et al., 2011)); 5) several of

the included studies focused on treatments that do not specifically target SA or NSSI (e.g.,

(Hollon et al., 1992, Wong, 2008, Kuipers et al., 1997)); 6) not all included studies considered

20
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SA or NSSI as primary outcomes (e.g., (Wong, 2008, Mufson et al., 2004)); 7) the inclusion

of studies with randomized antidepressant assignment or other forms of psychotherapy in the

TAU arm (e.g., (Brent et al., 2009, Donaldson et al., 2005)); 8) the between-study

heterogeneity in the follow-up duration could have led to exposure variability (however, we

included this factor as a moderator in the meta-regression); 9) the methodological approach of

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excluding studies with no events or no reported events may have led to a biased sample;

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however, only three studies were excluded for this reason; 10) the lack of consideration of not

published articles could have led to the risk of missing failed trials; 11) articles not written in

SC
English and that could have brought additional insights into psychotherapeutic treatments in

suicide were not included; 12) not all the potentially eligible studies were retained because of

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the lack of access to such articles, lack of data related to the outcomes of interest and lack of
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replies from the contacted authors.
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In conclusion, psychotherapy seems to be effective for SA treatment. However, trials with

lower risk of bias, more homogeneous outcome measures and longer follow-up are needed to
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confirm the findings of this meta-analysis.

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EP

Acknowledgements
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We are grateful to the authors who replied to our request for additional study data: Cedar R.
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Koons, Shelley McMain and Ryan Barnhart, Kirsten Morley, and Igor Weinberg. We would

like to thank Dr. Elisabetta Andermarcher for the careful linguistic revision of the manuscript.

Dr. Raffaella Calati received a grant from FondaMental Foundation, France. Prof. Philippe

Courtet received research grants from Servier, and fees for presentations at congresses or

participation in scientific boards from AstraZeneca, Bristol-Myers-Squibb, Janssen, Lilly,

Lundbeck, Otsuka, Roche and Servier.

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Study Treatments Medications Duration N of weekly Follow Sample Gender Mean age Diagnosis Main Main results Jadad
sessions up (females: scales
N, %)
(Hawton et Outpatient - Short-term 8 sessions in 1 year N=80 53, 66.25 29.34 Overdose SIS (-) 4
al., 1987) counseling (OC) vs treatment total RRS Two sub-groups benefited more
general practitioner SAS from OC: women and patients

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care BDI with dyadic problems
GHQ
(Salkovskis CBT vs TAU - 1 month 5 sessions in 1 year N=20 10, 50 27.24 Patients at BSSI CBT: 2
et al., total high risk of BSIS ↓ SI

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1990) repeated SA PQRST ↓ Repetition
(at least 2 POMS ↓ Depression
previous SA) BDI ↓ Hopelessness

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HS
(Linehan et DBT vs TAU Tapered off 1 year 2 1 year N=44 44, 100 18-45 BPD PHI DBT: 3
al., 1991) BDI ↓ Parasuicide
BHS ↓ Medically severe parasuicide
↑ Individual therapy

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RLI
↓ Inpatient psychiatric care

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duration
(Hollon et CT (alone or Randomized 3 months At most 20 3 N=64 ITT: 32.6±10.8 MDD BDI (-) 4
al., 1992) combined) vs treatment sessions months 51, 80 HRSD
imipramine assignment (14.9±11.5) in GAS

M
total
(McLeavey Interpersonal - 3-6 months 5.3±0.48 in 6 N=39 10, 25.6 24.44 Self- ICPS IPSST: 3
et al., Problem-Solving total months poisoning MEPS ↓ Self-poisoning
1994) Skills Training (dysthymia, SRPS ↑ Problem solving

D
(IPSST) vs short- dependent HS
term problem- personality

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oriented approach disorder,
alcohol abuse,
panic
disorder, no
EP
diagnosis)
(Kuipers et CBT and TAU vs Assessed 9 months In the first 9 N=60 22, 36.7 40.26 Medication- PSE ↓ BPRS 3
al., 1997) TAU phase weekly months resistant BPRS (-)
psychosis MADS
C

(van der Intensive in-patient - 1-4 days of - 12 N=274 180, 65.7 36.29 Suicide SIS (-) SA 3
Sande et and community hospitalization months attempters MADRS (-) SCL-90
al., 1997) intervention vs and treatment SCL-90 (-) HC
AC

TAU by problem HS
solving
approach
(Bateman Psychoanalytically Assessed 1.45 years 1) Weekly 18 N=38 22, 57.9 31.8 BPD SCID Psychoanalytically oriented 2
and oriented partial individual months SSHI partial
Fonagy, hospitalization vs psychotherapy SCL-90 hospitalization:
1999) TAU 2) Thrice BDI ↓ Suicidal and self-mutilatory
weekly STAI acts

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 ACCEPTED MANUSCRIPT

group SAS ↓ Inpatient care

psychotherapy IIP-C days
3) Weekly ↓ Depressive symptoms
expressive ↑ Social and interpersonal
therapy function
4) Weekly

PT
community
meeting
(Guthrie et Short-term IPT vs - 4 sessions in 6 N=119 66, 55.46 31.2±1.5 Adults who SSI IPT: 4
↓ SA

RI
al., 2001) TAU total, 1 per months had BDI
week deliberately ↓ SI
poisoned ↑ Satisfaction with treatment
themselves

SC
(Nordentoft Integrated treatment Part of the IT 2 years 1 year N=321 128, 39.9 27.0±6.3 First-episode SCAN IT: 2
et al., (IT) vs TAU schizophrenia- EPSIS ↓ Hopelessness
2002) spectrum IRAOS
disorder

U
(Tyrer et MACT vs TAU - 3 months 7 sessions in 1 year N=480 154, 32 32±11 Patients with HADS (-) 2
al., 2003) total recurrent GAF

AN
deliberate BHS
self-harm SFQ
(Verheul et DBT vs TAU Assessed 1 year 2 1 year N=58 58, 100.0 34.9±7.7 BPD with and BPDSI DBT: 2
al., 2003) without LPC ↓ Self-mutilating and self-

M
substance damaging impulsive behaviors
abuse ↑ Treatment retention

(Mufson et IPT vs TAU Assessed 3 months 12 sessions in 3 N=63 53, 84.13 15.12 MDD, HDRS IPT: 3

D
al., 2004) total, 1 per months dysthymia, BDI ↓ Depressive symptoms
week depressive CGAS ↑ Clinical improvement

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disorder not CGI ↓ Clinical severity
otherwise SAS ↑ Global functioning
specified ↑ Social functioning
or adjustment
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disorder with
depressed
mood
(Donaldson Skills-based SSRI alone: 6 months 10-14 6 N=39 7, 18 15.0±1.7 Suicide DISC Both groups: 1
C

et al., treatment 50% sessions in months attempters SIQ ↓ SI

2005) vs supportive SSRI plus total (MDD, CES-D ↓ Depressed mood
AC

relationship another disruptive STAXI

treatment medication: behavior
33% disorder,
Atypical substance use
antidepressant: disorder)
6%
Mood
stabilizer:
11%

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SBT = 60%
SRT = 50%
(Brown et CT vs enhanced CT: 51.7% 10 in total, 1, 18 N=120 73, 60.8 35 MDD: 77% HRSD CT: 5
al., 2005) usual care EUC: 53.6% 2 or as needed months Substance BDI ↓ SA
per week use disorder: BHS (-) SI
68% SSI ↓ Self-reported depression

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↓ Hopelessness
(Davidson CBT and TAU vs - 1 year Less than 1 1 year N=106 - 18-65 BPD ADSHI CBT: 5
et al., TAU (27±13 BDI ↓ Suicidal acts

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2006) sessions in STAI ↓ Positive symptom distress
total) BSI index
IIP ↓ State anxiety
↓ Dysfunctional beliefs

SC
(Linehan et DBT vs Assessed 1 year 2 2 years N=101 101, 100 29.29 BPD with SASII DBT: 5
al., 2006) community recent suicidal SBQ ↓ SA
treatment by non– and self- RLI ↓ Hospitalization

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behavioral injurious THI for SI
psychotherapy behaviors (at HRSD ↓ Medical risk
experts least 2 SA or ↓ Drop out

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self-injuries in ↓ Psychiatric hospitalizations
the past 5 ↓ Psychiatric emergency
years) department visits

M
(Wong, CBT vs control Assessed 10 weeks 10 sessions in 10 N=96 80, 79 37.4±9.4 MDD BDI CBT: 2
2008) group (no total weeks EC ↓ Depression
treatment) DAS ↑ Coping skills
↓ Negative emotions

D
↓ Dysfunctional attitudes
(Bateman MBT vs structured Assessed 18 months 140 sessions 18 N=134 107, 79.8 31.11 BPD GAF MBT: 5

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and clinical in total, 2 per months SCL-90 ↓ SA
Fonagy, management week BDI ↓ Hospitalization
2009) SAS
IIP-C
EP
(Brent et CBT and SSRI or Randomized 3 months Up to 1 per 3 N=334 - 12-18 MDD K-SADS- (-) 3
al., 2009) venlafaxine vs assignment to week months not responders PL
SSRI or treatment (8.3±3.6) to a previous CGI
venlafaxine alone SSRI CGAS
C

CDRS
BDI
AC

BHS
SIQ
(McMain DBT vs general 81.6% 1 year 2 2 years N=180 155, 86.1 30.4±9.9 BPD with at SASII No difference between groups 3
et al., psychiatric least 2 ZRS
2009) management suicidal or SCL-90-R
NSSI episodes STAXI
in the past 5 BDI
years IPP-C
(Vitiello et We grouped CBT Randomized 36 weeks 24-30 36 N=439 237, 54 14.6±1.5 MDD C-CASA CBT: 3

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al., 2009) (alone or assignment to sessions in weeks SIQ ↓ SA

combination) vs treatment total CDRS
fluoxetine or ADS
placebo CGI
BHS
RADS

PT
(Diamond Attachment-Based Assessed Around 10 in 6 N=66 55, 83.3 15.19 MDD, anxiety SSI ABFT: 3
et al., Family Therapy total months disorder or BDI ↓ SI
2010) (ABFT) vs externalizing

RI
enhanced usual care disorders
(ADHD,
ODD, CD)
(Asarnow Family-based CBT Assessed 1 month 1 session in 2 N=181 125, 69 14.7±2.0 Suicidal SACA CBT: 5

SC
et al., vs usual emergency total months youths (SA HASS ↑ Outpatient treatment
2011) department care and/or SI) CES-D Both:
enhanced by CBCL (-) clinical/functioning
provider education CBQ outcomes

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(Comtois et CAMS vs enhanced Assessed 1-3 months 4-12 weekly 1 year N=32 14, 38 36.8±10.1 Suicidal CSQ CAMS: 4
al., 2011) usual care sessions in patients SSI ↓ SI

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total (recent SA or OQ-45 ↓ Symptom distress
imminent RLI ↑ Hope
suicidal risk) OHS
SASII

M
(Esposito- CBT vs enhanced Assessed 1 year Weekly (6 18 N=40 24, 66.7 15.72±1.19 Co-occurring K-SADS CBT: 3
Smythers TAU months), bi- months alcohol or SIQ ↓ SA
et al., monthly (3 other drug use CIS ↓ Global impairment

D
2011) months) and disorder and ↓ Inpatient psychiatric
monthly (3 suicidality hospitalizations, emergency

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months) (SA or SI) department
visits, and arrests
(Hvid et OPAC program - 6 months 1 year N=133 95, 71.4 37.06 Wide range of Suicidal ↓ SA 4
al., 2011) (outreach, problem diagnoses acts ↓ Repetitive acts
EP
solving, Repetition
adherence,
continuity) vs TAU
(Klingberg CBT vs cognitive Assessed 9 months 20 sessions in 1 year N=198 87, 43.9 36.9±9.9 SKZ Severe No difference between groups 4
C

et al., remediation total adverse

2012) events
AC

(Pistorello DBT vs optimized DBT: 41.9% 1 year 2 18 N=63 51, 81 20.86±1.92 College SCID-I DBT: 4
et al., TAU TAU: 37.5% months students with SCID-II ↓ Suicidality
2012) at least 1 SASII ↓ NSSI
lifetime NSSI BDI events
act or SA and SBQ ↓ Depression
3 or more SAS ↓ BPD criteria
BPD GAF ↓ Psychotropic medication use
diagnostic ↑ Social adjustment
criteria

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(Wei et al., CT vs control group Assessed 3 months 10 sessions in 1 year N=159 119, 31.75 Patients who BSSI (-) 3
2013) (no treatment) vs total 74.84 had attempted HRSD
telephone suicide
intervention
(Morley et Opportunistic CBT - 6 months 8 sessions in 6 N=185 68, 36.76 36.09 Substance use SSI (-) 3
al., 2014) vs TAU total plus months disorders HADS

PT
group therapy SES

(Rudd et CBT vs TAU Assessed 3 months 12 sessions in 2 years N=152 133, 87.5 27.40 Military SCID-I CBT: 4
↓ SA

RI
al., 2015) total personnel SCID-II
(MDD, PTSD, SASII
substance BSSI
dependence, BDI

SC
other anxiety BAI
disorders) BHS

U
Table 1. Features of the included randomized controlled trials (RCTs) reporting the effects of psychotherapies versus treatment as usual (TAU)

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on suicide attempt (SA) or non-suicidal self-injury (NSSI) rates.

M
↑: increase; ↓: decrease; (-): no difference; SA: suicide attempt; NSSI: non-suicidal self-injury; SI: suicidal ideation; CAMS: collaborative

D
assessment and management of suicidality; CBT: cognitive behavioral therapy; CT: cognitive therapy; DBT: dialectical behavior therapy; IPT:
interpersonal psychotherapy; MACT: manual-assisted cognitive behavior therapy; MBT: mentalization-based treatment; TAU: treatment as

TE
usual; BPD: borderline personality disorder; MDD: major depressive disorder; PTSD: post-traumatic stress disorder; SKZ: schizophrenia; ADS:
Adolescent Depression Scale; ADSHI: Acts of Deliberate Self-Harm Inventory; BAI: Beck Anxiety Inventory; BDI: Beck Depression Inventory;
EP
BHS: Beck Hopelessness Scale; BPDSI: Borderline Personality Disorder Severity Index; BPRS: Brief Psychiatric Rating Scale; BSI: Brief
Symptom Inventory; BSIS: Beck Suicidal Intent Scale; BSSI: Beck Scale for Suicide Ideation; CBCL: Child Behavior Checklist; CBQ: Conflict
C

Behavior Questionnaire; C-CASA: Columbia Classification Algorithm of Suicidal Assessment; CDRS: Child Depression Rating Scale; CES-D:
Center for Epidemiological Studies Depression Scale; CGAS: Children’s Global Assessment Scale; CGI: Clinical Global Impressions scale; CIS:
AC

Columbia Impairment Scale; CSQ: Client Satisfaction Questionnaire; DAS: Dysfunctional Attitude Scale; DISC: Diagnostic Interview Schedule
for Children; EC: Emotions Checklist; EPSIS: European Parasuicide Study Interview Schedule; GAF: Global Assessment of Functioning; GAS:
Global Assessment Scale; GHQ: General Health Questionnaire; HADS: Hospital Anxiety and Depression Scale; HASS: Youth report on the
Harkavy Hasnis Scale; HRSD: Hamilton Rating Scale for Depression; HS: Hopelessness Scale; ICPS: Interpersonal Cognitive Problem Solving;
IFR: Index of Family Relations; IIP-C: Inventory of Interpersonal Problems - Circumflex version; IRAOS: Interview for Retrospective

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Assessment of Onset of Schizophrenia; K-SADS-PL: School Age Schedule for Affective Disorders and Schizophrenia for School-Aged
Children-Present and Lifetime Version; LPC: Lifetime Parasuicide Count; MADRS: Montgomery - Åsberg Depression Rating Scale; MADS:
Maudsley Assessment of Delusions Schedule; MEPS: Means-Ends Problem-Solving; OHS: Optimism and Hope Scale; OQ-45: Outcome
Questionnaire-45; PHI: Parasuicide History Interview; POMS: Profile of Mood States; PQRST: Personal Questionnaire Rapid Scaling

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Technique; PSE: Present Status Examination ICD-10; RADS: Reynolds Adolescent Depression Scale; RLI: Reasons for Living Inventory; RRS:
Risk of Repetition Scale; SACA: Service Assessment for Children and Adolescents; SAS: Social Adjustment Scale; SASII: Suicide Attempt

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Self-Injury Interview; SBQ: Suicidal Behaviors Questionnaire; SCAN: Schedules for Clinical Assessment in Neuropsychiatry; SCID-I and -II:
Structured Clinical Interview for DSM; SCL-90: Symptom Checklist-90; SES: Self-Efficacy Scale; SFQ: Social Functioning Questionnaire; SIQ:

SC
Suicidal Ideation Questionnaire; SIS: Suicide Intent Scale; SRPS: Self-Rating Problem-Solving scale; SSBS: Spectrum of Suicidal Behavior
Scale; SSHI: Suicide and Self-Harm Inventory; SSI: Scale for Suicide Ideation; STAI: State-Trait Anxiety Inventory; STAXI: Spielberger Anger

U
Expression Inventory; THI: Treatment History Interview; ZRS: Zanarini Rating Scale.

AN
M
D
TE
C EP
AC

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z p χ2 d.f. p I2 (%)
Suicide attempts
Adults 4.07 <0.0001 119.71 24 <0.00001 80
Adolescents 0.73 0.47 9.27 5 0.10 46
Outpatients 3.88 0.0001 107.60 27 <0.00001 75
Inpatients 1.39 0.17 22.22 2 <0.0001 91
Completers 1.81 0.07 24.91 5 0.0001 80
BPD 2.85 0.004 39.75 7 <0.00001 82
Depressed patients 1.37 0.17 12.69 4 0.01 68

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Schizophrenia-spectrum 0.42 0.68 0.88 2 0.64 0
Previously suicidal patients 2.34 0.02 26.88 13 0.01 52
Non-previously suicidal patients 3.31 0.0009 110.76 16 <0.00001 86

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Long-term psychotherapies 3.14 0.002 101.00 14 <0.00001 86
Short-term psychotherapies 2.84 0.005 28.64 15 0.02 48
TAU only as control condition 2.83 0.005 71.95 16 <0.00001 78

SC
CBT 1.56 0.12 28.04 11 0.003 61
DBT 1.71 0.09 17.35 4 0.002 77
CT 1.54 0.12 8.14 2 0.02 75

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MBT 2.19 0.03 6.89 1 0.009 85
IPT 0.53 0.60 13.56 1 0.0002 93
AN
Non-suicidal self-injury
Adults 1.28 0.20 18.40 6 0.005 67
Outpatients 0.26 0.80 14.46 6 0.02 58
BPD 1.08 0.28 18.40 5 0.002 73
M

Previously suicidal patients 0.19 0.85 2.58 2 0.28 22

Non previously suicidal patients 1.15 0.25 24.01 4 <0.0001 83
Long-term psychotherapies 1.08 0.28 18.40 5 0.002 73
D

Short-term psychotherapies 0.01 0.99 5.47 1 0.02 82

TAU only as control condition 0.82 0.41 15.17 5 0.01 67
TE

CBT 0.39 0.69 5.61 2 0.06 64

DBT 0.40 0.69 1.83 2 0.40 0
MBT 2.19 0.03 3.17 1 0.08 68
EP

NSSI (strictly defined) 1.51 0.13 1.50 2 0.47 0

Table 2. Results of the sensitivity analyses (NSSI: non-suicidal self-injury; BPD: borderline
C

personality disorder; CBT: cognitive behavioral therapy; DBT: dialectical behavior therapy;
AC

CT: cognitive therapy; MBT: mentalization-based treatment or psychoanalytically oriented

partial hospitalization; IPT: interpersonal psychotherapy).

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Estimate SE Lower Upper z p

limit limit

Suicide attempts

Jadad -0.25 0.10 -0.44 0.06 -2.59 0.01

PT
Gender (female) -1.40 0.52 -2.42 -0.38 -2.68 0.007

Age -0.01 0.02 -0.04 0.03 -0.40 0.69

RI
Weekly sessions -0.52 0.16 -0.84 -0.20 -3.18 0.001

SC
Total sessions -0.01 0.01 -0.01 0.01 -1.49 0.14

Psychotherapy duration 0.16 0.22 -0.27 0.59 0.73 0.46

(years)

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Follow-up duration (years) -0.32 0.23 -0.78 0.13 -1.39 0.16
AN
Table 3. Results of the meta-regression analyses of potential moderators of the suicide attempt
M

outcome.
D
TE
C EP
AC

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Figure 1. PRISMA flow diagram.

Identification

Records identified through Additional records identified

database searching through other sources

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(n = 6961) (n = 25)

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Records after duplicates removed
(n = 5026)

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Screening

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Records screened Records excluded
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(n = 500) (n = 4526)

Full-text articles excluded

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Full-text articles assessed (n = 340)

for eligibility Studies:
Eligibility

(n = 160) - not pertinent (n=266)

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- reviews or meta-analyses
(n=31);
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- did not report suicide

attempt/NSSI rates for
each group (n=37);
- compared different
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psychotherapeutic
interventions (n=6).
Included

Studies included in
quantitative synthesis Full-text articles excluded
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(meta-analysis) through exclusion criteria

(n = 32) (n = 128)
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Figure 2. Forest plot and risk of bias evaluation of trials comparing the effect of
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psychotherapeutic treatments and treatment as usual (TAU) on suicide attempt rates.

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Figure 3. Forest plot and risk of bias evaluation of trials comparing the effect of
psychotherapeutic treatments and treatment as usual (TAU) on non-suicidal self-injury
(NSSI)/self-harming behavior rates.

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