CD013668

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Psychosocial interventions for self-harm in adults (Review)
Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K
Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K.
Psychosocial interventions for self-harm in adults.
Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013668.
DOI: 10.1002/14651858.CD013668.pub2.
www.cochranelibrary.com

Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 22
OBJECTIVES.................................................................................................................................................................................................. 24
METHODS..................................................................................................................................................................................................... 24
RESULTS........................................................................................................................................................................................................ 29
Figure 1.................................................................................................................................................................................................. 30
Figure 2.................................................................................................................................................................................................. 34
Figure 3.................................................................................................................................................................................................. 35
DISCUSSION.................................................................................................................................................................................................. 62
Figure 4.................................................................................................................................................................................................. 67
Figure 5.................................................................................................................................................................................................. 68
Figure 6.................................................................................................................................................................................................. 69
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 71
ACKNOWLEDGEMENTS................................................................................................................................................................................ 72
REFERENCES................................................................................................................................................................................................ 74
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 96
RISK OF BIAS................................................................................................................................................................................................ 193
DATA AND ANALYSES.................................................................................................................................................................................... 196
Analysis 1.1. Comparison 1: CBT-based psychotherapy, Outcome 1: Repetition of SH at post-intervention.................................. 198
Analysis 1.2. Comparison 1: CBT-based psychotherapy, Outcome 2: Repetition of SH at six months............................................. 199
Analysis 1.3. Comparison 1: CBT-based psychotherapy, Outcome 3: Repetition of SH at 12 months.............................................. 199
Analysis 1.4. Comparison 1: CBT-based psychotherapy, Outcome 4: Repetition of SH at 24 months.............................................. 199
Analysis 1.5. Comparison 1: CBT-based psychotherapy, Outcome 5: Frequency of SH at post-intervention.................................. 200
Analysis 1.6. Comparison 1: CBT-based psychotherapy, Outcome 6: Frequency of SH at six months............................................. 200
Analysis 1.7. Comparison 1: CBT-based psychotherapy, Outcome 7: Time to SH repetition............................................................ 200
Analysis 1.8. Comparison 1: CBT-based psychotherapy, Outcome 8: Depression scores at post-intervention................................ 200
Analysis 1.9. Comparison 1: CBT-based psychotherapy, Outcome 9: Depression scores at six months.......................................... 201
Analysis 1.10. Comparison 1: CBT-based psychotherapy, Outcome 10: Depression scores at 12 months....................................... 201
Analysis 1.11. Comparison 1: CBT-based psychotherapy, Outcome 11: Depression scores at 24 months....................................... 201
Analysis 1.12. Comparison 1: CBT-based psychotherapy, Outcome 12: Hopelessness scores at post-intervention........................ 202
Analysis 1.13. Comparison 1: CBT-based psychotherapy, Outcome 13: Hopelessness scores at six months.................................. 202
Analysis 1.14. Comparison 1: CBT-based psychotherapy, Outcome 14: Hopelessness scores at 12 months................................... 202
Analysis 1.15. Comparison 1: CBT-based psychotherapy, Outcome 15: Suicidal ideation scores at post-intervention.................. 202
Analysis 1.16. Comparison 1: CBT-based psychotherapy, Outcome 16: Suicidal ideation scores at six months............................. 203
Analysis 1.17. Comparison 1: CBT-based psychotherapy, Outcome 17: Proportion reporting suicidal ideation............................. 203
Analysis 1.18. Comparison 1: CBT-based psychotherapy, Outcome 18: Suicide deaths by final follow-up..................................... 204
Analysis 1.19. Comparison 1: CBT-based psychotherapy, Outcome 19: Repetition of SH at 12 months (by repeater status)......... 204
Analysis 2.1. Comparison 2: DBT, Outcome 1: Repetition of SH by post-intervention...................................................................... 207
Analysis 2.2. Comparison 2: DBT, Outcome 2: Repetition of SH by 12 months................................................................................. 207
Analysis 2.3. Comparison 2: DBT, Outcome 3: Frequency of SH by post-intervention...................................................................... 208
Analysis 2.4. Comparison 2: DBT, Outcome 4: Treatment adherence: Proportion completing treatment....................................... 208
Analysis 2.5. Comparison 2: DBT, Outcome 5: Depression scores by post-intervention................................................................... 209
Analysis 2.6. Comparison 2: DBT, Outcome 6: Suicidal ideation scores by post-intervention.......................................................... 209
Analysis 2.7. Comparison 2: DBT, Outcome 7: Suicide deaths by post-intervention........................................................................ 210
Analysis 2.8. Comparison 2: DBT, Outcome 8: Suicide deaths by 12 months.................................................................................... 210
Analysis 2.9. Comparison 2: DBT, Outcome 9: Suicide deaths by 24 months.................................................................................... 211
Analysis 3.1. Comparison 3: Group-based emotion-regulation psychotherapy, Outcome 1: Repetition of SH at post- 212
intervention...........................................................................................................................................................................................
Psychosocial interventions for self-harm in adults (Review) i

Informed decisions.
Analysis 3.2. Comparison 3: Group-based emotion-regulation psychotherapy, Outcome 2: Frequency of repetition of SH at post- 212
intervention...........................................................................................................................................................................................
Analysis 3.3. Comparison 3: Group-based emotion-regulation psychotherapy, Outcome 3: Depression scores at post- 212
intervention...........................................................................................................................................................................................
Analysis 4.1. Comparison 4: Case management, Outcome 1: Repetition of SH at post-intervention.............................................. 213
Analysis 4.2. Comparison 4: Case management, Outcome 2: Suicide deaths at post-intervention................................................. 214
Analysis 5.1. Comparison 5: Remote contact interventions: Emergency cards, Outcome 1: Repetition of SH at post- 215
intervention...........................................................................................................................................................................................
Analysis 5.2. Comparison 5: Remote contact interventions: Emergency cards, Outcome 2: Repetition of SH at 12 months.......... 215
Analysis 6.1. Comparison 6: Remote contact interventions: Postcards, Outcome 1: Repetition of SH at post-intervention........... 218
Analysis 6.2. Comparison 6: Remote contact interventions: Postcards, Outcome 2: Repetition of SH at 12 months...................... 219
Analysis 6.3. Comparison 6: Remote contact interventions: Postcards, Outcome 3: Frequency of SH at post-intervention.......... 220
Analysis 6.4. Comparison 6: Remote contact interventions: Postcards, Outcome 4: Frequency of SH at 12 months...................... 221
Analysis 6.5. Comparison 6: Remote contact interventions: Postcards, Outcome 5: Frequency of SH at 24 months...................... 222
Analysis 6.6. Comparison 6: Remote contact interventions: Postcards, Outcome 6: Suicide deaths at post-intervention............. 222
Analysis 7.1. Comparison 7: Remote contact interventions: Telephone-based psychotherapy, Outcome 1: Repetition of SH at 223
post-intervention...................................................................................................................................................................................
Analysis 7.2. Comparison 7: Remote contact interventions: Telephone-based psychotherapy, Outcome 2: Depression scores at 223
Analysis 7.3. Comparison 7: Remote contact interventions: Telephone-based psychotherapy, Outcome 3: Suicide deaths at 224
Analysis 8.1. Comparison 8: Provision of information and support, Outcome 1: Repetition of SH at post-intervention................ 224
Analysis 8.2. Comparison 8: Provision of information and support, Outcome 2: Suicide deaths at post-intervention................... 225
Analysis 9.1. Comparison 9: Other multimodal interventions, Outcome 1: Repetition of SH at post-intervention......................... 226
Analysis 9.2. Comparison 9: Other multimodal interventions, Outcome 2: Time to SH repetition.................................................. 226
Analysis 9.3. Comparison 9: Other multimodal interventions, Outcome 3: Depression scores at post-intervention...................... 227
Analysis 9.4. Comparison 9: Other multimodal interventions, Outcome 4: Hopelessness scores at post-intervention.................. 227
Analysis 9.5. Comparison 9: Other multimodal interventions, Outcome 5: Suicide deaths at post-intervention........................... 227
ADDITIONAL TABLES.................................................................................................................................................................................... 227
APPENDICES................................................................................................................................................................................................. 230
WHAT'S NEW................................................................................................................................................................................................. 233
HISTORY........................................................................................................................................................................................................ 233
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 233
DECLARATIONS OF INTEREST..................................................................................................................................................................... 234
SOURCES OF SUPPORT............................................................................................................................................................................... 234
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 234
INDEX TERMS............................................................................................................................................................................................... 234
Psychosocial interventions for self-harm in adults (Review) ii

Informed decisions.
[Intervention Review]
Psychosocial interventions for self-harm in adults
Katrina G Witt1,2, Sarah E Hetrick3, Gowri Rajaram1,2, Philip Hazell4, Tatiana L Taylor Salisbury5, Ellen Townsend6, Keith Hawton7
1Orygen, Parkville, Melbourne, Australia. 2Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia.
3Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.
4Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia. 5Health Service and Population Research
Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. 6Self-Harm Research Group,
School of Psychology, University of Nottingham, Nottingham, UK. 7Centre for Suicide Research, Department of Psychiatry, University of
Oxford, Oxford, UK
Contact: Katrina G Witt, katrina.witt@orygen.org.au.
Editorial group: Cochrane Common Mental Disorders Group.

Publication status and date: New, published in Issue 4, 2021.
Citation: Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Psychosocial interventions for self-harm
in adults. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013668. DOI: 10.1002/14651858.CD013668.pub2.
ABSTRACT
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.
Psychosocial interventions for self-harm in adults (Review) 1

Informed decisions.
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.
PLAIN LANGUAGE SUMMARY
Psychosocial interventions for adults who self-harm
We have reviewed the interventional literature regarding psychosocial intervention treatment trials in the field. A total of 76 trials meeting
our inclusion criteria were identified. There may be beneficial effects for psychological therapy based on cognitive behavioural therapy
(CBT) approaches at longer follow-up time points, and for mentalisation-based therapy (MBT), and emotion-regulation psychotherapy
at the post-intervention assessment. There may also be some evidence of effectiveness of standard dialectical behaviour therapy (DBT)
on frequency of SH repetition. There was no clear evidence of effect for case management, information and support, remote contact
interventions (e.g. emergency cards, postcards, telephone-based psychotherapy), provision of information and support, and other
multimodal interventions.
Why is this review important?
Self-harm (SH), which includes intentional self-poisoning/overdose and self-injury, is a major problem in many countries and is strongly
linked with suicide. It is therefore important that effective treatments are developed for people who engage in SH. There has been an
increase in both the number of trials and the diversity of therapeutic approaches for SH in adults in recent years. It is therefore important
to assess the evidence for their effectiveness.
Who will be interested in this review?
Hospital administrators (e.g. service providers), health policy officers and third party payers (e.g. health insurers), clinicians working with
people who engage in SH, the people themselves, and their relatives.
What questions does this review aim to answer?
This review is an update of a previous Cochrane review from 2016 which found that CBT-based psychological therapy can result in fewer
individuals repeating SH whilst DBT may lead to a reduction in frequency of repeated SH. This updated review aims to further evaluate the
evidence for effectiveness of psychosocial interventions for people engaging in SH with a broader range of outcomes.
Which studies were included in the review?
To be included in the review, studies had to be randomised controlled trials of psychosocial interventions for adults who had recently
engaged in SH.

Informed decisions.
What does the evidence from the review tell us?
Overall, there were a number of methodological limitations across the trials included in this review. We found positive effects for
psychological therapy based on CBT approaches at longer follow-up assessments, and for mentalisation-based therapy (MBT), and
emotion-regulation psychotherapy on repetition of SH at post-intervention. There may also be some evidence of effects for standard
dialectical behaviour therapy (DBT) on frequency of SH repetition. However, remote contact interventions, case management, information
and support, and other multimodal interventions do not appear to have benefits in terms of reducing repetition of SH.
What should happen next?
The promising results for CBT-based psychotherapy at longer follow-up time points, and for MBT, group-based emotion regulation, and
DBT warrant further investigation to understand which people benefit from these types of interventions. Greater use of head-to-head trials
(where treatments are directly compared with each other) may also assist in identifying which component(s) from these often complex
interventions may be most effective.

SUMMARY OF FINDINGS
Summary of findings 1. Comparison 1.1: Individual-based CBT-based psychotherapy compared to TAU or another comparator for self-harm in adults
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Comparison 1.1: Individual-based CBT-based psychotherapy compared to TAU or another comparator for self-harm in adults
Patient or population: self-harm in adults

Intervention: CBT-based psychotherapy
Comparison: TAU or another comparator
Better health.
Informed decisions.
Trusted evidence.
Outcomes Anticipated absolute effects* (95% CI) Relative effect № of partici- Certainty of Comments
(95% CI) pants the evidence
Risk with com- Risk with CBT-based (studies) (GRADE)
parator psychotherapy
Repetition of Study population OR 0.35 238 ⊕⊕⊝⊝ Our confidence in the effect estimate of case man-
SH at post-in- (0.12 to 1.02) (4 RCTs) LOW 1,2 agement on repetition of SH at post-intervention is
tervention 200 per 1000 80 per 1000 limited. The true effect may be substantially differ-
(29 to 203) ent from the estimate of the effect.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and
its 95% CI).
CBT: cognitive behavioural therapy; CI: Confidence interval; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm; OR: Odds ratio.
GRADE Working Group grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 We downgraded this domain by one level as we rated any of the sources of risk of bias (as described in Assessment of risk of bias in included studies) at high risk for one of
the studies included in the pooled estimate.
2 We downgraded this domain by one level as the 95% CI for the pooled effect included the null value.
Summary of findings 2. Comparison 1.2: Group-based CBT-based psychotherapy compared to TAU or another comparator for self-harm in adults
Comparison 1.2: Group-based CBT-based psychotherapy compared to TAU or another comparator for self-harm in adults

Intervention: CBT-based psychotherapy
4
Outcomes Anticipated absolute effects* (95% Relative effect № of partici- Certainty of Comments
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CI) (95% CI) pants the evidence
(studies) (GRADE)
Risk with com- Risk with CBT-
parator based psy-
chotherapy
Repetition of Study population OR 0.66 313 ⊕⊕⊕⊝ We are moderately confident in the effect estimate
Better health.
Informed decisions.
Trusted evidence.
SH at post-in- (0.36 to 1.21) (1 RCT) MODERATE 1 of group-based CBT-based psychotherapy on repeti-
tervention 190 per 1000 134 per 1000 tion of SH at post-intervention. The true effect is likely
(78 to 221) to be close to the estimate of the effect, but there is a
possibility that it is substantially different.
its 95% CI).
CBT: cognitive behavioural therapy; CI: Confidence interval; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm; OR: Odds ratio.

Summary of findings 3. Comparison 2.1: DBT compared to TAU or another comparator for self-harm in adults
Comparison 2.1: DBT compared to TAU or another comparator for self-harm in adults

Intervention: DBT
(studies) (GRADE)
Risk with com- Risk with DBT
parator
5
Repetition of Study population OR 0.71 502 ⊕⊝⊝⊝ We have very little confidence in the effect estimate of
SH by post-in- (0.32 to 1.55) (6 RCTs) VERY LOW 1 2 3 DBT on repetition of SH at post-intervention. The true
tervention 682 per 1000 604 per 1000 effect is likely to be substantially different from the es-
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(407 to 769) timate of effect.
its 95% CI).
CI: Confidence interval; DBT: Dialectical behaviour therapy; OR: Odds ratio; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm; TAU: Treatment as usual.
Better health.
Informed decisions.
Trusted evidence.
1 We downgraded this domain by two levels as we rated any of the sources of risk of bias (as described in Assessment of risk of bias in included studies) at high risk for two or
more of the studies included in the pooled estimate.
2 We downgraded this domain by one level as the I2 value indicated substantial levels of heterogeneity.
Summary of findings 4. Comparison 2.2: DBT group-based skills training compared to TAU or another comparator for self-harm in adults
Comparison 2.2: DBT group-based skills training compared to TAU or alternative psychotherapy for self-harm in adults

Intervention: DBT group-based skills training
Outcomes Anticipated absolute effects* Relative effect № of partici- Certainty of Comments

(95% CI) (95% CI) pants the evidence
(studies) (GRADE)
parator group-based
skills training
attempted sui- (0.23 to 1.86) (1 RCT) MODERATE 1 of DBT group-based skills training on repetition of at-
cide at post-in- 364 per 1000 274 per 1000 tempted suicide at post-intervention. The true effect is
tervention (116 to 515) likely to be close to the estimate of the effect, but there
is a possibility that it is substantially different.
6
Repetition of Study population OR 0.88 66 ⊕⊕⊕⊝ We are moderately confident in the effect estimate of
NSSI at post-in- (0.33 to 2.34) (1 RCT) MODERATE 1 DBT group-based skills training on repetition of NSSI at
tervention 576 per 1000 544 per 1000 post-intervention. The true effect is likely to be close to
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(309 to 761) the estimate of the effect, but there is a possibility that
it is substantially different.
its 95% CI).
Better health.
Informed decisions.
Trusted evidence.
CI: Confidence interval; DBT: Dialectical behaviour therapy; NSSI: Non-suicidal self-injury; OR: Odds ratio; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm;
TAU: Treatment as usual.

Summary of findings 5. Comparison 2.3: DBT individual therapy compared to TAU or another comparator for self-harm in adults
Comparison 2.3: DBT individual therapy compared to TAU or another comparator for self-harm in adults

Intervention: DBT individual therapy
Outcomes Anticipated absolute effects* Relative effect № of partici- Certainty of Comments

(95% CI) (95% CI) pants the evidence

(studies) (GRADE)
parator individual
therapy
attempted sui- (0.54 to 3.91) (1 RCT) MODERATE 1 DBT individual therapy on repetition of attempted sui-
cide at post-in- 364 per 1000 455 per 1000 cide at post-intervention. The true effect is likely to be
tervention (236 to 691) close to the estimate of the effect, but there is a possibil-
ity that it is substantially different.
7
NSSI at post-in- (0.48 to 3.47) (1 RCT) MODERATE 1 DBT individual therapy on repetition of NSSI at post-in-
tervention 576 per 1000 636 per 1000 tervention. The true effect is likely to be close to the es-
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(394 to 825) timate of the effect, but there is a possibility that it is
substantially different.
its 95% CI).
Better health.
Informed decisions.
Trusted evidence.
CI: Confidence interval; DBT: Dialectical behaviour therapy; NSSI: Non-suicidal self-injury; OR: Odds ratio; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm;
TAU: Treatment as usual.

Summary of findings 6. Comparison 2.4: DBT prolonged exposure protocol compared to TAU or another comparator for self-harm in adults
Comparison 2.4: DBT prolonged exposure protocol compared to TAU or another comparator for self-harm in adults

Intervention: DBT prolonged exposure protocol

Risk with com- Risk with DBT pro- (studies) (GRADE)
parator longed exposure
protocol
SH at post-in- (0.08 to 5.68) (1 RCT) MODERATE1 of DBT prolonged exposure protocol on repetition
tervention 333 per 1000 251 per 1000 of SH at post-intervention. The true effect is likely
(38 to 740) to be close to the estimate of the effect, but there
is a possibility that it is substantially different.
its 95% CI).
8
CI: Confidence interval; DBT: Dialectical behaviour therapy; OR: Odds ratio; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm; TAU: Treatment as usual.
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Better health.
Informed decisions.
Trusted evidence.
Summary of findings 7. Comparison 3: MBT compared to TAU or another comparator for self-harm in adults
Comparison 3: MBT compared TAU or another comparator for self-harm in adults

Intervention: MBT
Risk with com- Risk with MBT (studies) (GRADE)
parator
Repetition of Study population OR 0.35 134 ⊕⊕⊕⊕ We are very confident that the true effect for MBT
SH at post-in- (0.17 to 0.73) (1 RCT) HIGH on repetition of SH at post-intervention lies close
tervention 492 per 1000 253 per 1000 to that of the estimate of the effect.
(141 to 414)

its 95% CI).
CI: Confidence interval; MBT: Mentalisation-based therapy; OR: Odds ratio; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm; TAU: Treatment as usual.

9
Summary of findings 8. Comparison 4: Emotion-regulation psychotherapy compared to TAU or another comparator for self-harm in adults
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Comparison 4: Emotion-regulation psychotherapy compared to TAU or another comparator for self-harm in adults

Intervention: Group-based emotion-regulation psychotherapy
Better health.
Informed decisions.
Trusted evidence.
Risk with com- Risk with Group-based (studies) (GRADE)
parator emotion-regulation psy-
chotherapy
Repetition of Study population OR 0.34 83 ⊕⊕⊕⊝ We are moderately confident that the true ef-
SH at post-in- (0.13 to 0.88) (2 RCTs) MODERATE1 fect of group-based emotion-regulation psy-
tervention 775 per 1000 539 per 1000 chotherapy on repetition of SH at post-inter-
(309 to 752) vention lies close to that of the estimate of
the effect.
its 95% CI).
CI: Confidence interval; OR: Odds ratio; RCT: Randomised controlled trial; RR: Risk ratio; SH: Self-harm; TAU: Treatment as usual.


1 We downgradedthis domain by one level as one study was suggestive of benefit, whilst the second trial of this intervention was not.
Summary of findings 9. Comparison 5: Psychodynamic psychotherapy compared to TAU or another comparator for self-harm in adults
Psychodynamic psychotherapy compared to TAU or another comparator for self-harm in adults

Intervention: Psychodynamic psychotherapy
10
(studies) (GRADE)
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Risk with com- Risk with Psy-
parator chodynamic psy-
chotherapy
SH at post-in- (0.13 to 1.56) (1 RCT) MODERATE 1 of psychodynamic psychotherapy on repetition of
Better health.
Informed decisions.
Trusted evidence.
tervention 133 per 1000 65 per 1000 SH at post-intervention. The true effect is likely to be
(20 to 194) close to the estimate of the effect, but there is a pos-
sibility that it is substantially different.
its 95% CI).

Summary of findings 10. Comparison 6: Case management compared to TAU or another comparator for self-harm in adults
Case management compared to TAU or another comparator for self-harm in adults

Intervention: Case management
(studies) (GRADE)
Risk with com- Risk with Case
parator management
Study population OR 0.78 1608 ⊕⊕⊝⊝ Our confidence in the effect estimate of case man-
(0.47 to 1.30) (5 RCTs) LOW 1 2 agement on repetition of SH at post-intervention is
11
limited. The true effect may be substantially differ-
Repetition of 114 per 1000 91 per 1000
ent from the estimate of the effect.
SH at post-in- (57 to 143)
tervention
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its 95% CI).
Better health.
Informed decisions.
Trusted evidence.
Summary of findings 11. Comparison 7: Structured GP follow-up compared to TAU or another comparator for self-harm in adults
Structured general practitioner (GP) follow-up compared to TAU or another comparator for self-harm in adults

Intervention: Structured general practitioner (GP) follow-up
(studies) (GRADE)
Risk with com- Risk with Struc-

parator tured general
practitioner (GP)
follow-up
Repetition of Study population OR 1.01 143 ⊕⊕⊝⊝ Our confidence in the effect estimate of structured
SH at post-in- (0.38 to 2.68) (1 RCT) LOW 1 2 general practitioner (GP) follow-up on repetition of SH
tervention (hos- 133 per 1000 134 per 1000 (according to hospital records) at post-intervention is
pital records) (55 to 291) limited. The true effect may be substantially different
from the estimate of the effect.
Repetition of Study population OR 2.56 123 ⊕⊕⊝⊝ Our confidence in the effect estimate of structured
SH at post- (0.80 to 8.15) (1 RCT) LOW 1 2 general practitioner (GP) follow-up on repetition of SH
12
intervention (according to emergency records) at post-intervention
72 per 1000 167 per 1000
(emergency is limited. The true effect may be substantially differ-
(59 to 389)
records) ent from the estimate of the effect.
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its 95% CI).
Better health.
Informed decisions.
Trusted evidence.
Summary of findings 12. Comparison 9.1: Emergency cards compared to TAU or another comparator for self-harm in adults
Comparison 9.1: Emergency cards compared to TAU or another comparator for self-harm in adults

Intervention: Emergency cards
Risk with com- Risk with Remote con- (studies) (GRADE)
parator tact interventions:

Emergency cards
Repetition of Study population OR 0.82 1039 ⊕⊕⊝⊝ Our confidence in the effect estimate of emer-
SH at post-in- (0.31 to 2.14) (2 RCTs) LOW 1 2 gency cards on repetition of SH at post-inter-
tervention 171 per 1000 145 per 1000 vention is limited. The true effect may be sub-
(60 to 306) stantially different from the estimate of the ef-
fect.
its 95% CI).
13
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Better health.
Informed decisions.
Trusted evidence.
Summary of findings 13. Comparison 9.2: Coping cards compared to TAU or another comparator for self-harm in adults
Comparison 9.2: Coping cards compared to TAU or another comparator for self-harm in adults

Intervention: Coping cards
(studies) (GRADE)
Risk with com- Risk with Coping
parator cards
SH at post-in- (0.00 to 1.45) (1 RCT) MODERATE 1 coping cards on repetition of SH at post-intervention.
tervention 156 per 1000 15 per 1000 The true effect is likely to be close to the estimate of
(0 to 212) the effect, but there is a possibility that it is substan-
tially different.

its 95% CI).

14
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Summary of findings 14. Comparison 9.4: Postcards compared to TAU or another comparator for self-harm in adults
Comparison 9.4: Postcards compared to TAU or another comparator for self-harm in adults

Intervention: Postcards
Better health.
Informed decisions.
Trusted evidence.
parator tact interventions: Post-
cards
Repetition of Study population OR 0.87 3277 ⊕⊝⊝⊝ We have very little confidence in the effect es-
SH at post-in- (0.62 to 1.23) (4 RCTs) VERY LOW 1 2 3 timate for postcards on repetition of SH. The
tervention 132 per 1000 117 per 1000 true effect is likely to be substantially differ-
(86 to 157) ent from the estimate of effect.
its 95% CI).


Summary of findings 15. Comparison 9.5: Telephone contact compared to TAU or another comparator for self-harm in adults
Comparison 9.5: Telephone contact compared to TAU or another comparator for self-harm in adults
15
Intervention: Telephone contact
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(studies) (GRADE)
Risk with com- Risk with Tele-
parator phone contact
Better health.
Informed decisions.
Trusted evidence.
Repetition of Study population OR 0.43 55 ⊕⊕⊝⊝ Our confidence in the effect estimate of telephone
SH at post-in- (0.04 to 5.02) (1 RCT) LOW 1 2 contact on repetition of SH at post-intervention is
tervention 77 per 1000 35 per 1000 limited. The true effect may be substantially differ-
(3 to 295) ent from the estimate of the effect.
its 95% CI).


Summary of findings 16. Comparison 9.6: Telephone contact, emergency cards, and letters compared to TAU or another comparator for self-harm in
adults
Comparison 9.6: Telephone contact, emergency cards, and letters compared to TAU or another comparator for self-harm in adults

Intervention: Telephone contact, emergency cards, and letters
(studies) (GRADE)
16
Risk with com- Risk with Remote con-
Telephone contact,
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emergency cards, and
letters
Repetition of Study population OR 1.05 303 ⊕⊕⊕⊝ We are moderately confident in the effect esti-
SH at post-in- (0.55 to 2.00) (1 RCT) MODERATE 1 mate of telephone contact, emergency cards,
tervention 139 per 1000 145 per 1000 and letters on repetition of SH at post-interven-
Better health.
Informed decisions.
Trusted evidence.
(82 to 244) tion. The true effect is likely to be close to the
estimate of the effect, but there is a possibility
that it is substantially different.
its 95% CI).

Summary of findings 17. Comparison 9.7: Telephone-based psychotherapy compared to TAU or another comparator for self-harm in adults
Comparison 9.7: Telephone-based psychotherapy compared to TAU or alternative psychotherapy for self-harm in adults

Intervention: Telephone-based psychotherapy
Telephone-based psy-
chotherapy
17
Repetition of Study population OR 0.36 185 ⊕⊕⊝⊝ Our confidence in the effect estimate of tele-
SH at post-in- (0.01 to 8.94) (2 RCTs) LOW 1 2 phone-based psychotherapy on repetition of
tervention 11 per 1000 4 per 1000 SH at post-intervention is limited. The true ef-
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(0 to 87) fect may be substantially different from the
estimate of the effect.
its 95% CI).
Better health.
Informed decisions.
Trusted evidence.

Summary of findings 18. Comparison 10: Provision of information and support compared to TAU or another comparator for self-harm in adults
Comparison 10: Provision of information and support compared to TAU or another comparator for self-harm in adults

Intervention: Provision of information and support

Risk with com- Risk with Provision (studies) (GRADE)
parator of information and
support
Repetition of Study population OR 1.09 1853 ⊕⊝⊝⊝ We have very little confidence in the effect esti-
SH at post-in- (0.79 to 1.50) (2 RCTs) VERY LOW 1 2 3 mate for information and support on repetition of
tervention 90 per 1000 97 per 1000 SH by the post-intervention assessment. The true
(72 to 129) effect is likely to be substantially different from the
estimate of effect.
18
its 95% CI).
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Better health.
Informed decisions.
Trusted evidence.
1 Publication bias is suspected as data from some centres have not been published.
Summary of findings 19. Comparison 11: Other multimodal interventions compared to TAU or another comparator for self-harm in adults
Comparison 11: Other multimodal interventions compared to TAU or another comparator for self-harm in adults

Intervention: Other multimodal interventions
Risk with com- Risk with Other (studies) (GRADE)
parator multimodal inter-
ventions

Repetition of Study population OR 0.61 1937 ⊕⊝⊝⊝ We have very little confidence in the effect esti-
SH at post-in- (0.37 to 1.30) (3 RCTs) VERY LOW 1 2 mate for other multimodal interventions on rep-
tervention 252 per 1000 189 per 1000 etition of SH at post-intervention. The true effect
(111 to 305) is likely to be substantially different from the esti-
mate of effect.
its 95% CI).

19
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1 We downgraded this domain by two levels as the I2 value indicated considerable levels of heterogeneity.
Better health.
Informed decisions.
Trusted evidence.
Summary of findings 20. Comparison 12.5: General hospital management compared to TAU or another comparator for self-harm in adults
Comparison 12.5: General hospital management compared to TAU or another comparator for self-harm in adults

Intervention: General hospital management
(studies) (GRADE)
Risk with com- Risk with General
parator hospital manage-
ment
SH at post-in- (0.14 to 7.69) (1 RCT) MODERATE 1 of general hospital management on repetition of SH
tervention 51 per 1000 53 per 1000 at post-intervention. The true effect is likely to be
(8 to 294) close to the estimate of the effect, but there is a pos-
sibility that it is substantially different.
its 95% CI).


20
Summary of findings 21. Comparison 12.8: Long-term therapy compared to TAU or another comparator for self-harm in adults
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Comparison 12.8: Long-term therapy compared to TAU or another comparator for self-harm in adults
Intervention: Long term therapy

Better health.
Informed decisions.
Trusted evidence.
(studies) (GRADE)
Risk with com- Risk with Long
parator term therapy
Repetition of Study population OR 1.00 80 ⊕⊕⊝⊝ Our confidence in the effect estimate of long-term
SH at post-in- (0.35 to 2.86) (1 RCT) LOW 1 2 therapy on repetition of SH at post-intervention is
tervention 225 per 1000 225 per 1000 limited.The true effect may be substantially different
(92 to 454) from the estimate of the effect.
its 95% CI).


21
Informed decisions.
BACKGROUND with a particularly high risk in men (Carroll 2014; Geulayov 2019).
One quarter of these deaths are estimated to occur within one
Description of the condition month after discharge, and almost 50% by three months (Forte
2019), although the risk of suicide appears to remain elevated for
Self-harm (SH), which includes all intentional acts of self-poisoning
a number of years (Geulayov 2019). A history of SH is the strongest
(such as intentional drug overdoses) or self-injury (such as self-
risk factor for suicide across a range of psychiatric disorders.
cutting), regardless of degree of suicidal intent or other types of
Repetition of SH further increases the risk of suicide (Zahl 2004).
motivation (Hawton 2003), has been a growing problem in most
countries. In Australia, for example, it is estimated that there are SH and suicide are the result of a complex interplay between
now more than 26,000 general hospitalisations for SH each year, genetic, biological, psychiatric, psychosocial, social, cultural, and
or a rate of 116.7 per 100,000 persons (Harrison 2014), similar other factors. Psychiatric disorders, particularly mood and anxiety
to rates observed in a number of other comparable countries disorders, are associated with the largest contribution to the risk
(Canner 2018; Griffin 2014; Morthorst 2016; Ting 2012; Wilkinson of both SH (Hawton 2013), and suicide in adults (Ferrari 2014).
2002). However, it is notable that rates of emergency department Personality disorders, including borderline personality disorder,
presentations for SH are often higher than hospitalisations (Bergen are also associated with SH, particularly frequent repetition.
2010; Corcoran 2015). In the UK, for example, higher rates of Alcohol use may also play an important role (Ferrari 2014). Both
emergency department presentations for SH in both females (442 psychological and biological factors appear to further increase
per 100,000) and males (362 per 100,000) have been reported vulnerability to SH. Psychological factors may include difficulties
(Geulayov 2016). There are also many more episodes of SH in problem-solving, low self-esteem, impulsivity, vulnerability to
occurring in the community that do not come to the attention having pessimistic thoughts about the future (i.e. hopelessness),
of clinical services. Worldwide, for example, the World Health and a sense of entrapment. Biological factors include disturbances
Organization (WHO) estimates that the rate of SH may be as high as in the serotonergic and stress response systems (Van Heeringen
400 per 100,000, according to self-report data (WHO 2014). 2014).
In contrast to suicide rates, rates of hospital-presenting SH are Description of the intervention
higher in females than in males in most countries (Canner 2018;
Griffin 2014; Masiran 2017; Morthorst 2016; Ting 2012; Wilkinson Psychological approaches used to treat adults who engage in SH
2002), with rates peaking in younger adults up to 24 years of age typically involve brief individual- or group-based psychological
(Perry 2012). However, this difference decreases across the life therapy. Treatment may vary in terms of initial management,
cycle (Hawton 2008). SH is less common in older people, but tends location of treatment, continuity, intensity, and frequency of
to be associated with higher suicidal intent (Hawton 2008), with contact with therapists. There is also considerable variation
consequent greater risk of suicide (Murphy 2012). among countries in the availability of services to provide such
interventions. Consequently, there is no standard psychosocial
For those who present to hospital, the most common method of treatment of SH in adults. However, in high-income countries,
SH is self-poisoning. Overdoses of analgesics and psychotropics, treatment generally consists of a combination of assessment,
especially paracetamol or acetaminophen, are common in some support, and individual psychological therapies. In lower and
countries, particularly high-income countries. Self-cutting is the middle-income countries, aftercare more usually involves various
next most frequent method used by those who present to hospital. forms of support, both face-to-face and via digital means.
However, in the community, self-cutting and other forms of self-
injury are far more frequent than self-poisoning (Müller 2016). How the intervention might work
SH is often repeated. Up to one-quarter of those who present Psychosocial interventions may address some of the underlying
to hospital with SH return to the same hospital within a year psychological risk factors associated with SH. The mechanisms
(Carroll 2014; Owens 2002), although some individuals may present of action of these interventions might help people improve their
to another hospital. Others may not present to hospital at all coping skills and tackle specific problems, manage psychiatric
given that studies identifying SH repetition via self-report suggest disorders, improve self-esteem, increase a sense of social
as many as one in five report further SH episodes following a connectedness, and reduce impulsivity and harmful reactions
hospital presentation (Carroll 2014). Repetition is more common to distressing situations. What follows is a description of the
in individuals who have a history of previous episodes of SH, psychosocial interventions that are typically available for adults
personality disorder, psychiatric treatment, and alcohol or drug who engage in SH behaviours.
misuse (Larkin 2014). Risks of repeat SH may also be associated
Cognitive behavioural therapy-based psychotherapy
with method. Rates of repetition are higher among those who
present to hospital following self-injury alone (Carroll 2014; Lilley Cognitive behavioural therapy (CBT)-based psychotherapy helps
2008), or combined self-injury and self-poisoning (Perry 2012), people identify and critically evaluate the ways in which they
compared to those who present for self-poisoning alone. interpret and evaluate disturbing emotional experiences and
events, and aims to help them change the ways in which they deal
SH is associated with suicide. The risk of death by suicide within with problems (Westbrook 2008). This is achieved in three steps:
one year among people who present to hospital following SH first, people are helped to change the ways in which they interpret
varies across studies from nearly 1% to over 3% (Liu 2020; Carroll and evaluate distressing emotions; second, they learn strategies to
2014; Owens 2002). This variation reflects the characteristics of help them change the way in which they think about the meanings
the population, and the background national suicide rate. In the and consequences of these emotions; finally, with the benefit of
UK, for example, during the first year after an episode of SH, the modified interpretation of emotions and events, they are helped to
risk of suicide is around 50 times that of the general population,

Informed decisions.
change their behaviour and develop positive functional behaviour expected to assess that person's needs, develop a care plan,
(Jones 2012). arrange for suitable care to be provided, monitor the quality of the
care provided, and maintain contact with the person" (Marshall
Problem-solving therapy (PST) is an integral part of CBT, although 2000a). Case management might have a significant role in the
it can be delivered as a therapy in and of itself. PST assumes aftercare of people who engage in SH because many of them
that ineffective and maladaptive coping behaviours that drive SH demonstrate poor treatment adherence, and because of the varied
might be overcome by helping the person to learn skills to actively, nature of the problems these individuals are often facing (Lizardi
constructively, and effectively solve the problems he or she faces 2010).
in their daily lives (Nezu 2010). PST typically involves identification
of the problem, generation of a range of solutions, implementation Remote contact interventions
of chosen solutions based on appraisal, and the evaluation of
Remote contact interventions, which may include letters, brief text
these solutions (D'Zurilla 2010). Treatment goals include helping
messages delivered by telephone, telephone calls, and postcards,
people to develop a positive problem-solving orientation, use
are low-resource and non-intrusive interventions that seek to
rational problem-solving strategies, reduce the tendency to avoid
maintain long-term contact with people. These interventions
problem-solving, and reduce the use of impulsive problem-solving
provide a sense of ongoing concern, and may mitigate the sense
strategies.
of social isolation reported by many people who engage in SH.
Dialectical behaviour therapy They may also help to improve their knowledge about triggers and
warning signs for SH, provide them with information on alternative
In contrast to CBT and PST, which focus on changing behaviour coping behaviours to SH, and where they can access help (Milner
and cognitive patterns, the focus of dialectical behavioural therapy 2016).
(DBT) is to provide people with the skills to develop an awareness
and acceptance of thoughts and emotions, including painful or These interventions may also be combined with emergency card
distressing internal experiences, without judgement or attempts interventions, which encourage people to seek help when they
to alter, suppress, avoid, or otherwise change these experiences feel distressed, and offer on-demand emergency contact with
(Lynch 2006). The primary treatment goals of DBT are three-fold: psychiatric services or inpatient care. The aim is to reduce the risk
to reduce SH, reduce behaviours that interfere with the success of SH by facilitating rapid access to care.
of treatment, such as treatment non-adherence, and reduce any
other factors that may adversely affect the person's quality of life Other multimodal interventions
(e.g. frequency or duration of psychiatric hospitalisations) (Linehan Any of the above active psychosocial interventions may also be
1993). combined into a multimodal approach (Högberg 2008).
Mentalisation-based therapy Why it is important to do this review
Mentalisation refers to the ability to understand the behaviour of
SH is a major social and healthcare problem. It represents
both one's self and others in terms of motivational and emotional
significant morbidity, is often repeated, and is linked with suicide.
states (Allen 2008). Maladaptive and impulsive coping behaviours,
Many countries now have suicide prevention strategies, all of which
including SH, are presumed to arise from a disrupted ability
include a focus on improved management of people presenting
to engage in these processes. In mentalisation-based therapy
with SH (WHO 2014). SH also leads to substantial healthcare
(MBT), the goal is to help people understand their emotions and
costs (Sinclair 2011). In the UK, the overall median cost per
behaviours, and develop strategies to regulate them to minimise
episode of SH has been estimated to be £809, although costs
the risk that they will engage in SH during times of distress.
are significantly higher for cases of combined self-injury and self-
Emotion-regulation psychotherapy poisoning, compared to either self-injury of self-poisoning alone.
These costs are mainly attributable to health-service level contact
Emotion-regulation psychotherapy is based on DBT, Acceptance (i.e. inpatient stay or admission to intensive care; Tsiachristas 2017).
and Commitment Therapy (ACT), and emotion-focused therapy.
It includes psychoeducation, identification of emotions, In the UK, the National Collaborating Centre for Mental Health
distress tolerance, emotional acceptance, behavioural activation, (NCCMH) produced the first guideline on the treatment of SH
developing alternative coping strategies, impulse control, and behaviours in 2004 (NCCMH 2004). This guideline focused on the
identifying and clarifying valued directions. short-term physical and psychological management of SH. This
guidance was updated in 2011, using interim data from a previous
Psychodynamic psychotherapy version of this review as the evidence base, and focused on
Psychodynamic approaches focus on affective experiences, the longer-term psychological management of SH (NICE 2011).
exploring and understanding the unconscious meaning and Subsequently, similar guidelines have been published by the Royal
function of SH, and exploring and resolving difficulties College of Psychiatrists (Royal College of Psychiatrists 2014), the
in interpersonal relationships, and resulting emotional Royal Australian and New Zealand College of Psychiatrists (Carter
difficulties, within a therapeutic relational framework (Yakeley 2016), and German Professional Associations and Societies (Plener
2018). 2016), amongst others (Courtney 2019).
Case management In 2021, the guidance contained in the 2011 NICE guidelines for the
longer-term management of SH will be due for updating. Therefore,
"In its simplest form...case management is a means of coordinating we are updating our review (Hawton 2016), in order to provide
services. Each...person is assigned a 'case manager' who is contemporary evidence to guide clinical policy and practice.

Informed decisions.
OBJECTIVES 3. Mentalisation-based therapy (MBT) versus TAU or another

comparator;
To assess the effects of psychosocial interventions for self-harm 4. Emotion-regulation psychotherapy versus TAU or another
(SH) compared to comparison types of care (e.g. treatment as usual, comparator;
routine psychiatric care, enhanced usual care, active comparator)
5. Psychodynamic psychotherapy versus TAU or another
for adults (aged 18 years or older) who engage in SH.
comparator;
METHODS 6. Case management versus TAU or another comparator;
7. Structured general practitioner (GP) follow-up versus TAU or
Criteria for considering studies for this review another comparator;
Types of studies 8. Brief emergency department-based interventions versus TAU or
another comparator;
We considered all randomised controlled trials (RCTs) of specific 9. Remote contact interventions versus TAU or another
psychosocial interventions versus treatment as usual, routine comparator;
psychiatric care, enhanced usual care, active comparator, or a
10.Provision of information and support versus TAU or another
combination of these, in the treatment of adults with a recent
comparator;
(within six months of trial entry) presentation for self-harm (SH).
All RCTs (including cluster-RCTs [cRCTs] and cross-over trials) were 11.Other multimodal interventions versus TAU or another
eligible for inclusion regardless of publication type or language; comparator;
however, we excluded quasi-randomised trials. 12.Other mixed interventions versus TAU or another comparator.
Types of participants Comparators

While exact eligibility criteria often differ both within and between Treatment-as-usual (TAU) is likely to vary widely between settings
regions and countries (Witt 2020a), we included participants of both and between studies conducted over different time periods (Witt
sexes and all ethnicities, who were 18 years and older, with a recent 2018). Following previous work, we defined TAU as routine clinical
(i.e. within six months of trial entry) presentation to hospital or care that the person would receive had they not been included
clinical services for SH. in the study (i.e. routine care or 'standard disposition'; Hunt
2013). Other comparators could include no specific treatment,
We defined SH as all intentional acts of self-poisoning (such as or enhanced usual care, which refers to TAU that has, in some
intentional drug overdoses) or self-injury (such as self-cutting), way, been supplemented, such as by providing psychoeducation,
regardless of the degree of suicidal intent or other types of assertive outreach, or more regular contact with case managers,
motivation (Hawton 2003). This definition includes acts intended to and standard assessment approaches.
result in death ('attempted suicide'), those without suicidal intent
(e.g. to communicate distress, to temporarily reduce unpleasant Types of outcome measures
feelings; sometimes termed 'non-suicidal self-injury'), and those
For all outcomes, we were primarily interested in quantifying the
with mixed motivation. We did not distinguish between attempted
effect of treatment assignment to the intervention at baseline,
suicide and non-suicidal self-injury in this review, because there is
regardless of whether the intervention was received as intended
a high level of co-occurrence between them, and the two cannot
(i.e. the intention-to-treat effect).
be distinguished in any reliable way, including on levels of suicidal
intent (Klonsky 2011). Lastly, the motivations for SH are complex Primary outcomes
and can change, even within a single episode (De Beurs 2018).
The primary outcome measure in this review was the occurrence
We excluded trials in which participants presented to clinical of repeated SH over a maximum follow-up period of two years.
services for suicidal ideation only (i.e. without evidence of SH). Repetition of SH may be identified through self-report, collateral
report, clinical records, or research monitoring systems. As we
Types of interventions wished to incorporate the maximum data from each trial, we
Categorisation of the interventions in this review was informed by included both self-reported and hospital records of SH, where
the trials themselves, and based on consensus discussions among available. Preference was given to clinical records over self-report
members of the review team, who have considerable experience in where a trial reported both measures. We also reported proportions
both research and clinical practice related to SH. However, based on of participants repeating SH, frequency of repeat episodes, and
the previous version of this review (Hawton 2016), we anticipated time to SH repetition (where available).
the following groupings:
Secondary outcomes
Interventions Given increasing interest in the measurement of outcomes of
These included the following: importance to those who engage in SH (Owens 2020b), we planned
to analyse data for the following secondary outcomes (where
1. Cognitive behavioural therapy (CBT)-based psychotherapy (e.g. available) over a maximum follow-up period of two years:
CBT, problem-solving therapy [PST]) versus TAU or another
Treatment adherence
comparator;
2. Dialectical behaviour therapy (DBT) versus TAU or another This was assessed using a range of measures of adherence,
comparator; including: pill counts, changes in blood measures, and the

Informed decisions.
proportion of participants that both started and completed We searched for retraction statements and errata once the included
treatment. studies were selected.
Depression We also searched the World Health Organization International

This was assessed as either continuous data, by scores on Clinical Trials Registry Platform, and the US National Institutes of
psychometric measures of depression symptoms, for example, Health Ongoing Trials Register ClinicalTrials.gov to identify ongoing
total scores on the Beck Depression Inventory (BDI; Beck 1961), trials.
or scores on the depression subscale of the Hospital Anxiety and The search was based on population only, participants who self-
Depression Scale (HADS; Zigmond 1983), or as dichotomous data as harm (all ages). Records were screened to identify trials which were
the proportion of participants who met defined diagnostic criteria relevant to this review and two others (Witt 2021a; Witt 2021b).
for depression.
Searching other resources
Hopelessness
Conference abstracts
This was assessed as either continuous data, by scores on
psychometric measures of hopelessness, for example, total In addition to conference abstracts retrieved via the main electronic
scores on the Beck Hopelessness Scale (BHS; Beck 1974), or as search, we also screened the proceedings of recent (last five years)
dichotomous data as the proportion of participants reporting conferences organised by the largest scientific committees in the
hopelessness. field:
General functioning 1. International Association for Suicide Prevention (both global

This was assessed as either continuous data, by scores on congresses and regional conferences);
psychometric measures of general functioning, for example, total 2. Joint International Academy of Suicide Research and American
scores on the Global Assessment of Functioning (GAF; APA 2000), Foundation for Suicide Prevention International Summits on
or as dichotomous data as the proportion of participants reporting Suicide Research.
improved general functioning.
Reference lists
Social functioning
We also checked the reference lists of all relevant RCTs, and
This was assessed as either continuous data, by scores on the reference lists of major reviews that included a focus on
psychometric measures of social functioning, for example, total psychosocial interventions for SH in adults (Bornheimer 2020;
scores on the Social Adjustment Scale (SAS; Weissman 1999), or Briggs 2019; Calati 2016; D'Anci 2019; DeCou 2019; Ghanbari 2015;
as dichotomous data as the proportion of participants reporting Gøtzsche 2017; Hawton 2016; Hanratty 2019; Hetrick 2016; Inagaki
improved social functioning. 2019; Krysinska 2017; Meerwijk 2016; Milner 2015; Milner 2016;
Padmanathan 2020; Riblet 2017; Tighe 2018).
Suicidal ideation
Correspondence
This was assessed as either continuous data, by scores on
psychometric measures of suicidal ideation, for example, total We consulted the corresponding authors of trials, and other experts
scores on the Beck Scale for Suicidal Ideation (BSSI; Beck 1988), or in the field to find out if they are aware of any ongoing or
as dichotomous data as the proportion of participants reaching a unpublished RCTs on the psychosocial treatment of adults who
defined cut-off for ideation. engage in SH that were not identified by the electronic searches.
Suicide Data collection and analysis

This included register-recorded deaths, or reports from collateral Selection of studies
informants, such as family members or neighbours.
Review authors KW, KH, and one of either SH, GR, TTS, ET, or
Search methods for identification of studies PH, independently assessed the titles of reports identified by the
electronic search for eligibility. We distinguished between:
Electronic searches
An information specialist searched the following databases 1. eligible or potentially eligible trials for retrieval, in which any
(to 4 July 2020), using relevant subject headings (controlled psychosocial intervention was compared with a comparator (i.e.
vocabularies) and search syntax as appropriate for each TAU, routine psychiatric care, standard disposition, no specific
resource: Cochrane Common Mental Disorders Specialised Register treatment, enhanced usual care);
(Appendix 1), Cochrane Library (Central Register of Controlled 2. ineligible, general treatment trials, not for retrieval (i.e. where
Trials; CENTRAL), Cochrane Database of Systematic Reviews there was no control treatment).
(CDSR), MEDLINE Ovid, Embase Ovid, and PsycINFO Ovid (Appendix
All trials identified as potentially eligible for inclusion then
2).
underwent a second screening. Pairs of review authors, working
A date restriction was applied to the search as the search was to independently from one another, screened the full text of eligible
update an earlier version of this review (Hawton 2016). However, or potentially eligible trials to identify whether the trial met our
we did not apply any further restrictions on language or publication inclusion criteria. We resolved disagreements in consultation with
status to the searches. the senior review author (KH). Where disagreements could not be
resolved from the information reported in the trial, or where it

Informed decisions.
was unclear whether the trial satisfied our inclusion criteria, we Assessment of risk of bias in included studies
contacted corresponding trial authors for additional clarification.
Highly biased studies are more likely to overestimate treatment
We identified and excluded duplicate records, and collated multiple effectiveness (Moher 1998). Review author KW and one of either
reports of the same trial, so that each trial, rather than each SH, or GR independently evaluated the risk of bias for the primary
report, represented the unit of interest in the review. We recorded outcome (i.e. repetition of SH at post-intervention) by using version
the selection process in sufficient detail to complete a PRISMA 2 of the Cochrane Risk of Bias tool, RoB 2 (Sterne 2019). This tool
flow diagram (Liberati 2009), and completed a 'Characteristics of encourages consideration of the following domains:
excluded studies' table.
1. Bias in the randomisation process;
Data extraction and management 2. Deviations from the intended intervention (assignment to
intervention);
Review author KW and one of either SH, or GR independently
3. Missing outcome data;
extracted data from the included trials, using a standardised
extraction form. Where there were any disagreements, they were 4. Bias in the measurement of the outcome;
resolved in consensus discussions with KH. 5. Bias in the selection of the reported result.
Data extracted from each eligible trial included the following: For cluster-RCTs, we also evaluated the following:
1. Participant information: number randomised, number lost to 1. Bias arising from the timing of identification and recruitment of
follow-up or withdrawn, number analysed, mean or median participants.
age, sex composition, diagnoses, diagnostic criteria, inclusion
criteria, and exclusion criteria; Signalling questions in the RoB 2 tool provided the basis for the
tool’s domain-level judgements about the risk of bias. Two review
2. Methods: trial design, total duration of the trial, details of any
authors independently judged each source of potential bias as low
'run-in' period (if applicable), number of trial centres and their
risk, high risk, or some concerns. An overall 'Risk of bias' judgement
location, setting, and date;
was then made for each study by combining ratings across these
3. Intervention(s): details of the intervention, including dose, domains. Specifically, if any of the above domains were rated at
duration, whether concomitant treatments were permitted and high risk, the overall 'Risk of bias' judgement was rated at high risk.
details of these treatments, and any excluded treatments; We reported this overall judgement, which could be low risk, high
4. Comparator(s): details on the comparator, including dose, risk, or some concerns, in the text of the review, and in the 'Risk of
duration, whether concomitant treatments were permitted and bias' tables.
details of these treatments, and any excluded treatments;
5. Outcomes: raw data for each eligible outcome (see Types of Where inadequate details were provided in the original report, we
outcome measures), details of other outcomes specified and contacted corresponding trial authors to provide clarification. We
reported, and time points at which outcome were reported; resolved disagreements through discussions with KH.
6. Notes: source of trial funding, and any notable conflicts of We entered and organised our RoB 2 assessments on an Excel
interest of trial authors. spreadsheet (Microsoft Excel RoB2 Macro), and made them
We extracted both dichotomous and continuous outcomes data available as electronic supplements.
from eligible trials. As the use of non-validated psychometric Measures of treatment effect
scales is associated with bias, we extracted continuous data only
if the psychometric scale used to measure the outcome of interest Dichotomous outcomes
had been previously published in a peer-reviewed journal, and was
We summarised dichotomous outcomes, such as the number
not subjected to item, scoring, or other modification by the trial
of participants engaging in a repeat SH episode, or number of
authors (Marshall 2000b).
deaths by suicide, using the summary odds ratio (OR) and the
We planned the following main comparisons: accompanying 95% confidence interval (CI), as the OR is the
most appropriate effect size statistic for summarising associations
1. Cognitive behavioural therapy (CBT)-based psychotherapy (e.g. between two dichotomous groups (Fleiss 1994). Time to SH
CBT, problem-solving therapy [PST]) versus TAU or another repetition was summarised using the hazard ratio (HR) and its
comparator; accompanying 95% CI.
2. Dialectical behaviour therapy (DBT) versus TAU or another
Continuous outcomes
comparator;
3. Mentalisation-based therapy (MBT) versus TAU or another For outcomes measured on a continuous scale, we used mean
comparator; differences (MDs) and accompanying 95% CI where the same
4. Emotion-regulation psychotherapy versus TAU or another outcome measure was used. Where different outcome measures
comparator; were used, we used the standardised mean difference (SMD) and its
accompanying 95% CI.
5. Case management versus TAU or another comparator;
6. Remote contact interventions versus TAU or another We aggregated trials in a meta-analysis only where treatments were
comparator; sufficiently similar. For trials that could not be included in a meta-
7. Other multimodal interventions versus TAU or another analysis, we provided narrative descriptions of the results.
comparator.
Informed decisions.
Hierarchy of outcomes analyse data using measures that statistically accounted for the
cluster design. Where this was not possible, we planned to analyse
Where a trial measured the same outcome, for example,
data using the effective sample size. However, the trial authors
depression in two or more ways, we planned to use the most
were unable to provide values for either the inter-cluster correlation
common measure across trials in any meta-analysis. We also
coefficient or the design effect, and further, there was no similar
planned to report scores from other measures in a supplementary
cluster-RCT of this intervention approach from which these values
table.
could be approximated. We were therefore unable to statistically
Timing of outcome assessment account for the effects of clustering in this trial.
The primary end point for this review was post-intervention (i.e. In future updates of this review, should we be able to obtain
at the conclusion of the treatment period). We also reported information on either the inter-cluster correlation coefficient or the
outcomes for the following secondary end points (where data were design effect, we will follow the guidance outlined in Higgins 2019a.
available):
Cross-over trials
1. Between zero and six months after the conclusion of the
A primary concern with cross-over trials is the carry-over
treatment period;
effect, in which the effect of the intervention treatment (e.g.
2. Between six and 12 months after the conclusion of the treatment pharmacological, physiological, psychological) influences the
period; participant's response to the subsequent control condition
3. Between 12 and 24 months after the conclusion of the treatment (Elbourne 2002). As a consequence, on entry to the second phase
period. of the trial, participants may differ systematically from their initial
state, despite a wash-out phase. In turn, this may result in a
Where there was more than one outcome assessment within a time concomitant underestimation of the effectiveness of the treatment
period, we used data from the last assessment in the time period, intervention (Curtin 2002a; Curtin 2002b).
unless different outcomes were assessed at different time points.
For treatment adherence, we also planned to use within-treatment One trial included in the current review used cross-over
results. methodology (Marasinghe 2012). To protect against the carry-over
effect, we only extracted data from the first phase of this trial, prior
Unit of analysis issues to cross-over.
Zelen design trials
Studies with multiple treatment arms
Trials in this area are increasingly using Zelen's method, in
Five trials in the current review included multiple treatment arms
which consent is obtained subsequent to randomisation and
(Andreoli 2015; Armitage 2016; Linehan 2015; Stewart 2009; Wei
treatment allocation (Witt 2020a). This design may lead to bias if,
2013. For two of these trials (Andreoli 2015; Stewart 2009), it was
for example, participants allocated to one particular arm of the
possible to combine data from the two intervention arms given
trial disproportionally refuse to provide consent for participation
their similarity. For the remaining three, however, two different
or, alternatively, if participants only provide consent if they are
psychotherapies were compared (Armitage 2016; Linehan 2015; Wei
allowed to cross over to the other treatment arm (Torgerson 2004).
2013. Therefore, we included information from these trials in both
We identified five trials that used Zelen's design (Carter 2005; Gysin- categories of intervention using data from the relevant intervention
Maillart 2016; Hatcher 2011; Hatcher 2015; Hatcher 2016). Where arm. As we did not combine data from the intervention arms in
possible, we therefore analysed data for these trials using data any meta-analysis, we used the same comparator arm data for both
for all randomised participants as this is consistent with Zelen’s analyses.
original intention (Zelen 1979), and preserves randomisation. This
Studies with adjusted effect sizes
was typically possible for our primary outcome, repetition of SH,
as this was generally ascertained from clinical, hospital, and/or Where trials reported both unadjusted and adjusted effect sizes, we
medical records in these five trials. However, for certain self- included only observed, unadjusted effect sizes.
reported secondary outcome measures, data were only reported
on the basis of those who consented to participation. We therefore Dealing with missing data
planned to conduct sensitivity analyses to investigate what impact,
We did not impute missing data, as we considered that the
if any, the inclusion of these trials may have on the pooled estimate
bias that would be introduced by doing this would outweigh
of treatment effectiveness.
any benefit of increased statistical power that may have been
Cluster-randomised trials gained by including imputed data. However, where authors omitted
standard deviations (SD) for continuous measures, we contacted
Cluster randomisation, for example by clinician or general practice, corresponding authors to request missing data. Where missing data
can lead to overestimation of the significance of a treatment could not be provided, we calculated missing SDs using other data
effect, resulting in an inflation of the nominal type I error rate, from the trial, such as CIs, based on methods outlined in Higgins
unless appropriate adjustment is made for the effects of clustering 2019b.
(Donner 2002; Kerry 1998).
Assessment of heterogeneity
One trial included in this review used cluster randomisation
(Bennewith 2002). We had planned to follow the guidance outlined Between-study heterogeneity can be assessed using either the Chi2
in Higgins 2019a. Specifically, where possible, we planned to or I2 statistics. However, in this review, we used only the I2 statistic
to quantify inconsistency, as this is considered to be more reliable
Informed decisions.
(Deeks 2019). The I2 statistic indicates the percentage of between- by these factors, otherwise, there is the risk that doing so could lead
study variation due to chance, and can take any value from 0% to to confounding.
100% (Deeks 2019).
Randomisation was stratified by sex in five trials (Carter 2005;
We used the following values to denote relative importance of Hvid 2011; McAuliffe 2014; Walton 2020; Van der Sande 1997).
heterogeneity, as per Deeks 2019: Six trials also stratified randomisation by repeater status (Gratz
2014; Hatcher 2015; Hatcher 2016; McAuliffe 2014; Morthorst 2012;
1. unimportant: 0% to 40%; Mouaffak 2015).
2. moderate: 30% to 60%;
3. substantial: 50% to 90%; Investigation of heterogeneity
4. considerable: 75% to 100%. Several meta-analyses were associated with substantial levels of
between-study heterogeneity (i.e. I2 ≥ 75%). For these analyses, KW
We also took the magnitude and direction of effects and strength of and KH firstly independently triple-checked data to ensure these
evidence for heterogeneity into account (e.g. the CI for I2). were correctly entered. Next, we investigated the source of this
heterogeneity using a formal statistical approach as outlined in
Where substantial levels of heterogeneity were found, we explored Viechtbauer 2020.
reasons for this heterogeneity (see Subgroup analysis and
investigation of heterogeneity for details). Sensitivity analysis
Assessment of reporting biases We planned to undertake the following sensitivity analyses,
where appropriate, to test whether key methodological factors or
Reporting bias occurs when the decision to publish a particular decisions may have influenced the main result:
trial is influenced by the direction and significance of the results
(Egger 1997). Research suggests, for example, that trials with 1. Where a trial made use of Zelen's method of randomisation (see
statistically significant findings are more likely to be submitted for Unit of analysis issues);
publication and, subsequently, be accepted for publication, leading 2. Where a trial contributed to substantial between-study
to possible overestimation of the true treatment effect (Hopewell heterogeneity (see Subgroup analysis and investigation of
2009). heterogeneity).
To assess whether trials included in any meta-analysis were Five trials used Zelen's design (Carter 2005; Gysin-Maillart 2016;
affected by reporting bias, we planned to enter data into a funnel Hatcher 2011; Hatcher 2015; Hatcher 2016). We were therefore
plot when a meta-analysis included results of at least ten trials. able to undertaken sensitivity analyses, excluding these trials, to
Should evidence of any small study effects be identified, we investigate what impact, if any, Zelen's design had on the pooled
planned to explore reasons for funnel plot asymmetry, including estimate of treatment effectiveness. We reported results of these
the presence of possible publication bias (Egger 1997). sensitivity analyses in the text.
Data synthesis Additionally, several meta-analyses were associated with
For the purposes of this review, we calculated the pooled odds substantial levels of between-study heterogeneity. We also
ratio (OR) and accompanying 95% CI using the random-effects reported results of these sensitivity analyses in the text, alongside
model, as this is the most appropriate model for incorporating discussion of the likely causes of these differences.
heterogeneity between studies (Deeks 2019). We used the Mantel-
Haenszel method for dichotomous data, and the inverse variance Summary of findings and assessment of the certainty of the
method for continuous data. We conducted all analyses in Review evidence
Manager 5.4 (Review Manager 2020). For each comparison, we planned to construct a 'Summary of
findings' table for our primary outcome measure, repetition of
Subgroup analysis and investigation of heterogeneity SH post-intervention, following the recommendations outlined in
Subgroup analyses Schünemann 2019. These tables provide information concerning
the overall quality of the evidence from all included trials that
We planned to undertake the following subgroup analyses where measured the outcome. We assessed the quality of evidence across
there were sufficient data to do so: the following domains:
1. sex (males versus females); 1. 'Risk of bias' assessment;
2. repeater status (first SH episode versus repeat SH episode). 2. Indirectness of evidence;
Given the increasing use of enhanced usual care rather than 3. Unexplained heterogeneity or inconsistency of results;
TAU in trials in this field (Witt 2020a), we also planned to 4. Imprecision of effect estimates;
undertake subgroup analyses to determine whether comparator 5. Potential publication bias.
choice influenced the pattern of results observed.
For each of these domains, we downgraded the evidence from
Formal tests for subgroup differences were undertaken in Review high certainty by one level (for serious) or by two levels (for very
Manager 5.4 (Review Manager 2020). However, it is only possible to serious). For risk of bias, we downgraded this domain by one level
undertake these subgroup analyses if randomisation was stratified when we rated any of the sources of risk of bias (as described
in Assessment of risk of bias in included studies) at high risk for

Informed decisions.
any of the studies included in the pooled estimate, or by two 3. Low certainty: further research is very likely to have an
levels when we rated multiple studies at high risk for any of these important impact on our confidence in the estimate of effect,
sources. For indirectness of evidence, we considered the extent to and may change the estimate;
which trials included in any meta-analysis used proxy measures 4. Very low certainty: we are very uncertain about the estimate.
to ascertain repetition of SH; we downgraded this domain by one
level if one study used proxy measures, and by two levels if multiple We constructed 'Summary of findings' tables using GRADEpro GDT
studies used proxy measures. For unexplained heterogeneity or software (GRADEpro GDT 2015).
inconsistency of results, we downgraded this domain by one level
where the I2 value indicated substantial levels of heterogeneity, or Reaching conclusions
by two levels where the I2 value indicated considerable levels of We based our conclusions only on findings from the quantitative
heterogeneity. For imprecision, we downgraded this domain by one or narrative synthesis of the studies included in this review. Our
level where the 95% CI for the pooled effect included the null value. recommendations for practice and research suggest priorities for
Finally, for the potential publication bias domain, we considered future research, and outline remaining uncertainties in the area.
any evidence of funnel plot asymmetry (if available), as well as
other evidence such as suspected selective availability of data, and RESULTS
downgraded by one or more levels where publication bias was
suspected. Description of studies
We then used these domains to rate the overall quality of evidence Results of the search
for the primary outcome according to the following: For this update, a total of 7186 records were found using the search
strategy as outlined in Appendix 1 and Appendix 2. Five further
1. High certainty: further research is very unlikely to change our
records were identified following correspondence and discussion
confidence in the estimate of effect;
with researchers in the field. After deduplication, the initial number
2. Moderate certainty: further research is likely to have an was reduced to 4678. Of these, 4454 were excluded following
important impact on our confidence in the estimate of effect, title/abstract screening, whist a further 157 were excluded after
and may change the estimate; reviewing the full texts (Figure 1).

Informed decisions.
Figure 1. Study Flow Diagram
Included studies 1991; Linehan 2006; Marasinghe 2012; McAuliffe 2014; McMain 2009;
Owens 2020; Patsiokas 1985; Priebe 2012; Slee 2008; Sreedaran
In the previous version of this review (Hawton 2016), 55 trials
2020; Stewart 2009; Tapolaa 2010; Turner 2000; Tyrer 2003; Vaiva
of psychosocial interventions for self-harm (SH) in adults were
2006; Walton 2020; Wei 2013; Weinberg 2006).
included. The present update located 21 new trials of psychosocial
interventions for SH in adults. The present review therefore Design
includes 76 non-overlapping trials (see the Characteristics of
included studies tables for further information on these trials). Most trials (97.4%) randomised at the individual-level employing
either simple randomisation (Allard 1992; Armitage 2016; Beautrais
Unpublished data were obtained from the trial authors for 42 of 2010; Brown 2005; Clarke 2002; Crawford 2010; Davidson 2014;
these trials (Bateman 2009; Beautrais 2010; Bennewith 2002; Brown Dubois 1999; Evans 1999a; Evans 1999b; Fleischmann 2008;
2005; Carter 2005; Cedereke 2002; Clarke 2002; Crawford 2010; Gibbons 1978; Gratz 2006; Hawton 1981; Hawton 1987; Kapur
Davidson 2014; Dubois 1999; Fleischmann 2008; Gratz 2006; Gratz 2013; Liberman 1981; McLeavey 1994; Morgan 1993; Mousavi
2014; Guthrie 2001; Gysin-Maillart 2016; Harned 2014; Hassanian- 2015; Mousavi 2017; Naidoo 2014; O'Connor 2015; O'Connor 2020;
Moghaddam 2011; Hatcher 2011; Hatcher 2015; Hatcher 2016; Patsiokas 1985; Sahin 2018; Salkovskis 1990; Slee 2008; Stewart
Husain 2014; Hvid 2011; Kapur 2013; Kawanishi 2014; Linehan 2009; Tapolaa 2010; Torhorst 1987; Torhorst 1988; Turner 2000; Van
Informed decisions.
Heeringen 1995; Wang 2016; Waterhouse 1990; Wei 2013; Weinberg Torhorst 1987; Torhorst 1988; Van der Sande 1997), whilst in
2006; Welu 1977), or a restricted randomisation scheme such two older trials, treatment was delivered in an inpatient setting
as adaptive minimisation (Linehan 2015), blocked randomisation (Liberman 1981; Waterhouse 1990). In the remaining five trials,
(Amadéo 2015; Andreoli 2015; Grimholt 2015; Guthrie 2001; the intervention was delivered while individuals were receiving
Hassanian-Moghaddam 2011; Husain 2014; Lin 2020; McMain treatment in hospital and/or the emergency department (Armitage
2009; McMain 2017; Priebe 2012; Sreedaran 2020; Vaiva 2018), or 2016; Crawford 2010; O'Connor 2015; O'Connor 2017; O'Connor
minimisation procedure (Bateman 2009, Harned 2014, Kawanishi 2020).
2014; Linehan 1991; Linehan 2006; O'Connor 2017; Owens 2020)
procedure. One trial used a matched pair randomisation procedure Participants and participant characteristics
(Cedereke 2002). Nine trials used stratification (Gratz 2014; Hvid The included trials comprised a total of 21,414 participants. All had
2011; McAuliffe 2014; Morthorst 2012; Mouaffak 2015; Tyrer 2003; engaged in at least one episode of SH prior to trial entry. A history of
Vaiva 2006; Van der Sande 1997; Walton 2020). Five used Zelen's SH prior to the index episode (i.e. a history of multiple episodes of
design (Carter 2005; Gysin-Maillart 2016; Hatcher 2011; Hatcher SH) was a requirement for participation in 17 trials (Bateman 2009;
2015; Hatcher 2016). Evans 1999b; Gratz 2006; Gratz 2014; Harned 2014; Liberman 1981;
Linehan 1991; Linehan 2006; McMain 2009; Mousavi 2015; Mousavi
In one trial, cluster randomisation was used (Bennewith 2002). One
2017; Priebe 2012; Sahin 2018; Salkovskis 1990; Torhorst 1988; Tyrer
trial was a cross-over RCT (Marasinghe 2012).
2003; Weinberg 2006). In 20 trials, around half of the sample had
Setting a history of multiple episodes of SH (Allard 1992; Brown 2005;
Cedereke 2002; Evans 1999a; Guthrie 2001; Gysin-Maillart 2016;
Of the 76 independent RCTs included in this review, one-quarter Hatcher 2011; Hatcher 2015; Hatcher 2016; Kapur 2013; Kawanishi
(25.0%) were from the UK (Bateman 2009; Bennewith 2002; 2014; Lin 2020; Morthorst 2012; Mouaffak 2015; O'Connor 2017;
Clarke 2002; Crawford 2010; Davidson 2014; Evans 1999a; Evans Owens 2020; Slee 2008; Torhorst 1987; Van der Sande 1997; Welu
1999b; Gibbons 1978; Guthrie 2001; Hawton 1981; Hawton 1987; 1977) Only one trial excluded those with a history of multiple
Kapur 2013; Morgan 1993; O'Connor 2017; Owens 2020; Priebe episodes of SH prior to trial entry (Morgan 1993).
2012; Salkovskis 1990; Tyrer 2003; Waterhouse 1990), 14 were
from the USA (Brown 2005; Gratz 2006; Gratz 2014; Harned Information on the methods of SH for the index episode was not
2014; Liberman 1981; Linehan 1991; Linehan 2006; Linehan 2015; reported in half (k = 38; 50.0%) of the trials (Allard 1992; Amadéo
O'Connor 2015; O'Connor 2020; Patsiokas 1985; Turner 2000; 2015; Andreoli 2015; Armitage 2016; Bateman 2009; Cedereke 2002;
Weinberg 2006; Welu 1977), four from France (Dubois 1999; Davidson 2014; Dubois 1999; Evans 1999b; Fleischmann 2008;
Mouaffak 2015; Vaiva 2006; Vaiva 2018), four from New Zealand Gratz 2006; Gratz 2014; Hvid 2011; Kapur 2013; Liberman 1981;
(Beautrais 2010; Hatcher 2011; Hatcher 2015; Hatcher 2016), three Lin 2020; Linehan 1991; Linehan 2006; Linehan 2015; Marasinghe
from Australia (Carter 2005; Stewart 2009; Walton 2020), three from 2012; McMain 2009; Morthorst 2012; Mousavi 2017; Naidoo 2014;
Canada (Allard 1992; McMain 2009; McMain 2017), three from Iran O'Connor 2020; Patsiokas 1985; Priebe 2012; Sahin 2018; Salkovskis
(Hassanian-Moghaddam 2011; Mousavi 2015; Mousavi 2017), two 1990; Sreedaran 2020; Stewart 2009; Tapolaa 2010; Turner 2000;
from Denmark (Hvid 2011; Morthorst 2012), two from Germany Tyrer 2003; Walton 2020; Wang 2016; Wei 2013; Weinberg 2006). Full
(Torhorst 1987; Torhorst 1988), two from the Netherlands (Slee details of the methods used at the index episode for the remaining
2008; Van der Sande 1997), two from the Republic of Ireland trials is provided in Table 1. Whilst the predominance of participants
(McAuliffe 2014; McLeavey 1994), two from Switzerland (Andreoli engaging in self-poisoning in the majority of these trials is reflective
2015; Gysin-Maillart 2016), two from Sweden (Cedereke 2002; Sahin of the typical pattern observed in those who present to hospital,
2018), two from Taiwan (Lin 2020; Wang 2016), and one was from or in the community, SH more often involves self-cutting and other
each of Belgium (Van Heeringen 1995), China (Wei 2013), Finland forms of self-injury (Müller 2016).
(Tapolaa 2010), French Polynesia (Amadéo 2015), India (Sreedaran
2020), Japan (Kawanishi 2014), Malaysia (Armitage 2016), Norway Whilst most trials included both male and female participants, the
(Grimholt 2015), Pakistan (Husain 2014), South Africa (Naidoo majority of participants in the 71 trials that reported information
2014), and Sri Lanka (Marasinghe 2012). One was a multicentre trial on sex were female (61.9%), reflecting the typical pattern for SH
conducted in a number of countries (Fleischmann 2008). (Hawton 2008). Of the 64 trials that reported information on age,
the weighted mean age of participants at trial entry was 31.8 years
In the majority of trials, participants were identified following a (SD: 11.7 years).
clinical presentation for SH. In 16 trials (21.1%), participants were
identifying following referral to outpatient mental health and/or In the 38 trials that reported information on psychiatric diagnoses
specialist personality disorder treatment services (Bateman 2009; (Allard 1992; Amadéo 2015; Andreoli 2015; Bateman 2009; Brown
Gratz 2006; Gratz 2014; Harned 2014; Liberman 1981; Linehan 2005; Carter 2005; Cedereke 2002; Clarke 2002; Crawford 2010;
1991; Linehan 2006; Linehan 2015; McMain 2009; McMain 2017; Davidson 2014; Dubois 1999; Evans 1999a; Evans 1999b; Gibbons
Priebe 2012; Sahin 2018; Salkovskis 1990; Walton 2020; Wang 2016; 1978; Gratz 2006; Gratz 2014; Gysin-Maillart 2016; Harned 2014;
Weinberg 2006). All participants in these trials had a history of Kawanishi 2014; Lin 2020; Linehan 2006; Linehan 2015; McLeavey
SH resulting in presentation to clinical services within six months 1994; McMain 2009; McMain 2017; Morgan 1993; Mouaffak 2015;
preceding trial entry. Priebe 2012; Sahin 2018; Slee 2008; Sreedaran 2020; Turner 2000;
Tyrer 2003; Vaiva 2018; Van der Sande 1997; Van Heeringen
For most trials (85.5%), treatment was delivered in an outpatient 1995; Walton 2020; Wei 2013), participants were most commonly
setting or in the participants' home environment. In four trials, diagnosed with major depression (56.7%), followed by any other
acute-phase treatment was delivered in an inpatient setting mood disorder (37.6%), any personality disorder (31.6%), any
followed by outpatient follow-up appointments (Amadéo 2015; anxiety disorder (26.7%), and substance use disorder (26.7%). A

Informed decisions.
total of 14 trials focused specifically on participants diagnosed Evans 1999b; Fleischmann 2008; Gibbons 1978; Gratz 2006; Gratz
with borderline personality disorder (Andreoli 2015; Bateman 2009; 2014; Grimholt 2015; Guthrie 2001; Gysin-Maillart 2016; Hassanian-
Gratz 2006; Gratz 2014; Harned 2014; Linehan 1991; Linehan 2006; Moghaddam 2011; Hatcher 2011; Hatcher 2015; Hatcher 2016;
Linehan 2015; McMain 2009; McMain 2017; Sahin 2018; Turner 2000; Hawton 1987; Husain 2014; Hvid 2011; Kapur 2013; Lin 2020;
Walton 2020; Weinberg 2006), and three focused on participants Linehan 1991; McAuliffe 2014; McMain 2009; Morgan 1993; Mouaffak
diagnosed with any personality disorder (Davidson 2014; Evans 2015; Mousavi 2017; O'Connor 2015; O'Connor 2017; O'Connor
1999b; Priebe 2012). Only two trials reported information on the 2020; Owens 2020; Patsiokas 1985; Priebe 2012; Sahin 2018;
proportion of participants without psychiatric diagnoses at trial Salkovskis 1990; Slee 2008; Stewart 2009; Tapolaa 2010; Tyrer
entry (Evans 1999a; Sreedaran 2020). In these two trials, a small 2003; Vaiva 2006; Vaiva 2018; Van der Sande 1997; Van Heeringen
proportion (15.1%) were not diagnosed with a major psychiatric 1995; Wang 2016; Weinberg 2006; Welu 1977). The remaining trials
disorder. compared the effectiveness of the intervention to alternative forms
of psychotherapy (Harned 2014; Hawton 1981; Liberman 1981;
Information on comorbid diagnoses was reported in eight trials Linehan 2006; Linehan 2015; McLeavey 1994; Mousavi 2015; Naidoo
(Andreoli 2015; Bateman 2009; Davidson 2014; Gratz 2014 Harned 2014; Sreedaran 2020; Torhorst 1987; Torhorst 1988; Turner 2000;
2014; Mouaffak 2015; Sahin 2018; Turner 2000). Under one-half Walton 2020), waiting list (Marasinghe 2012; McMain 2017), no
(40.9%) were diagnosed with comorbid psychiatric diagnoses, treatment (Waterhouse 1990; Wei 2013), or enhanced usual care
typically comorbid mood or anxiety disorders and personality (EUC; Kawanishi 2014; Morthorst 2012).
disorders, although the nature of these comorbidities was not
always clearly reported in these trials. In three further trials (Carter Outcomes
2005; McMain 2009; Slee 2008), the median number of psychiatric
Primary outcome
diagnoses was greater than two, indicating that most participants
in these trials were also diagnosed with more than one psychiatric Information on the primary outcome, repetition of SH, was
disorder; however, none of the three reported further information available for all but two (3.0%) of the included trials (Patsiokas
on specific diagnoses. 1985; Sreedaran 2020).
Interventions In the majority of trials, repetition of SH was ascertained either from

self-reported information alone (Amadéo 2015; Armitage 2016;
The trials included in this review investigated the effectiveness of Brown 2005; Davidson 2014; Fleischmann 2008; Gratz 2006; Gratz
various forms of psychosocial interventions: 2014; Harned 2014; Hassanian-Moghaddam 2011; Husain 2014;
1. Cognitive behavioural therapy (CBT)-based psychotherapy (e.g. Liberman 1981; Linehan 1991; Linehan 2006; Linehan 2015; McMain
CBT, problem-solving therapy [PST]) versus TAU or another 2009; Mousavi 2015; Mousavi 2017; Naidoo 2014; O'Connor 2015;
comparator; O'Connor 2020; Priebe 2012; Sahin 2018; Slee 2008; Tapolaa 2010;
Torhorst 1987; Turner 2000; Walton 2020; Wei 2013; Weinberg 2006),
2. Dialectical behaviour therapy (DBT) versus TAU or another
followed by self-reported information supplemented by clinical,
comparator;
hospital, and/or medical records (Bateman 2009; Cedereke 2002;
3. Mentalisation-based therapy (MBT) versus TAU or another Evans 1999b; Grimholt 2015; Guthrie 2001; Gysin-Maillart 2016; Hvid
comparator; 2011; Lin 2020; Mouaffak 2015; Tyrer 2003; Vaiva 2006; Vaiva 2018),
4. Emotion-regulation psychotherapy versus TAU or another or self-reported information supplemented with information from
comparator; a collateral informant (e.g. a general practitioner [GP]) (McLeavey
5. Psychodynamic psychotherapy versus TAU or another 1994; McMain 2017; Van Heeringen 1995; Waterhouse 1990; Welu
comparator; 1977).
6. Case management versus TAU or another comparator;
For the remaining 23 trials, information on repetition of SH
7. Structured general practitioner (GP) follow-up versus TAU or was obtained from clinical, hospital, and/or medical records
another comparator; (Andreoli 2015; Beautrais 2010; Bennewith 2002; Clarke 2002;
8. Brief emergency department-based interventions versus TAU or Crawford 2010; Evans 1999a; Gibbons 1978; Hatcher 2011; Hatcher
another comparator; 2015; Hatcher 2016; Kapur 2013; Morgan 1993; Morthorst 2012;
9. Remote contact interventions versus TAU or another O'Connor 2017; Owens 2020; Salkovskis 1990; Stewart 2009; Van der
comparator; Sande 1997), from monitoring systems (Carter 2005; Hawton 1981;
10.Provision of information and support versus TAU or another Hawton 1987), or from clinical, hospital, and/or medical records
comparator; supplemented with information from collateral informants (Allard
1992).
11.Other multimodal interventions versus TAU or another
comparator; In one trial (McAuliffe 2014), mixed methods were used to
12.Other mixed interventions versus TAU or another comparator. determine repetition of SH. Specifically, self-reported information
was used at the post-intervention and six-month follow-up
Comparators assessments, whereas data on hospital representations were used
Of the 76 RCTs included in this review, the majority (76.3%) at the 12-month follow-up assessment in this trial.
compared the intervention to TAU (Allard 1992; Amadéo 2015;
Andreoli 2015; Armitage 2016; Bateman 2009; Beautrais 2010; For five trials, information on the source of the data for repetition
Bennewith 2002; Brown 2005; Carter 2005; Cedereke 2002; Clarke of SH was not clearly reported (Dubois 1999; Kawanishi 2014;
2002; Crawford 2010; Davidson 2014; Dubois 1999; Evans 1999a; Marasinghe 2012; Torhorst 1988; Wang 2016).

Informed decisions.
Secondary outcomes Social functioning

Treatment adherence Social functioning was assessed using the Social Adjustment Scale
Of the 28 trials that reported information on treatment adherence, (SAS; Weissman 1999) in just over half (55.6%) of the nine trials
this was assessed using a variety of methods. This included the that reported information on this outcome (Bateman 2009; Hawton
proportion of participants who completed the full course of the 1981; Hawton 1987; McMain 2017; Torhorst 1988), the Social
intervention treatment (Andreoli 2015; Bateman 2009; Bennewith Functioning Questionnaire (SFQ; Tyrer 1990) in two trials (Evans
2002; Brown 2005; Crawford 2010; Evans 1999b; Grimholt 2015; 1999b; Tyrer 2003), and the social performance subscale of the
Harned 2014; Husain 2014; Kawanishi 2014; Lin 2020; Linehan Social Behaviour Assessment Schedule (SBAS; Platt 1983) in one
2015; McAuliffe 2014; McLeavey 1994; McMain 2009; McMain 2017; trial (Waterhouse 1990). In one further trial, an idiosyncratic scale
O'Connor 2017; Owens 2020; Priebe 2012; Slee 2008; Sreedaran was used (Gibbons 1978).
2020; Torhorst 1987; Torhorst 1988; Turner 2000; Walton 2020; Suicidal ideation
Van Heeringen 1995), although for some trials, corresponding
information on the proportion completing treatment in the Eighteen trials assessed suicidal ideation using the BSSI (Brown
comparator arm was not clearly reported. A smaller number of trials 2005; Cedereke 2002; Davidson 2014; Grimholt 2015; Guthrie
reported information on the total number of treatment sessions 2001; Gysin-Maillart 2016; Hatcher 2011; Hawton 1981; Husain
attended (Allard 1992; Brown 2005; McLeavey 1994; Torhorst 1988; 2014; Lin 2020; Marasinghe 2012; McAuliffe 2014; O'Connor 2015;
Van der Sande 1997). O'Connor 2020; Patsiokas 1985; Salkovskis 1990; Stewart 2009;
Turner 2000), three trials used the Suicide Behaviors Questionnaire
Depression (SBQ; Linehan 1981) (Linehan 2006; Linehan 2015; Weinberg 2006),
Depression was assessed using the BDI in just under half (47.6%) of one trial used the Scale for Suicidal Ideators (SSI; Schotte 1982)
the 42 trials that reported information on this outcome (Armitage (Linehan 1991), one the suicidal ideation subscale of the Psychiatric
2016; Bateman 2009; Brown 2005; Fleischmann 2008; Gibbons Status Schedule (PSS; Spitzer 1970) (Waterhouse 1990), and one
1978; Grimholt 2015; Guthrie 2001; Gysin-Maillart 2016; Hawton the suicidal ideation subscale of the Suicide Risk Inventory (SRI;
1987; Husain 2014; Liberman 1981; Linehan 1991; Marasinghe Hsu 1997) (Wang 2016). Six trials measured suicidal ideation
2012; McAuliffe 2014; McMain 2009; McMain 2017; Salkovskis dichotomously as the proportion with self-reported suicidal
1990; Slee 2008; Tapolaa 2010; Turner 2000), followed by the ideation (Andreoli 2015; Hassanian-Moghaddam 2011; Liberman
depression subscale of the HADS in six trials (Davidson 2014; 1981; Mousavi 2015; Mousavi 2017; Wei 2013).
Evans 1999b; Hatcher 2011; Hatcher 2015; Hatcher 2016; Tyrer Suicide
2003), the Hamilton Rating Scale for Depression (HRSD; Hamilton
1960) in eight trials (Andreoli 2015; Brown 2005; Harned 2014; Lin In over half of the 60 trials (60.0%) that recorded information on
2020; Linehan 2006; Linehan 2015; Turner 2000; Wei 2013), the suicide, the method used to ascertain this outcome was not clearly
Depression Anxiety Stress Scales (DASS; Lovibond 1995) in two reported (Andreoli 2015; Bateman 2009; Beautrais 2010; Brown
trials (Gratz 2006; Gratz 2014), the Lorr and McNair Mood Scale 2005; Clarke 2002; Davidson 2014; Dubois 1999; Gratz 2006; Gratz
(LMMS; McNair 1964) in one trial (Hawton 1981), the Montgomery- 2014; Grimholt 2015; Guthrie 2001; Gysin-Maillart 2016; Harned
Åsberg Depression Rating Scale (MADRS; Montgomery 1979) in one 2014; Husain 2014; Kapur 2013; Lin 2020; Linehan 1991; Linehan
trial (Van der Sande 1997), and the Zung Self-Rating Depression 2006; Linehan 2015; Marasinghe 2012; McLeavey 1994; McMain
Scale (ZSRDS; Zung 1965) in one trial (Liberman 1981). In two trials, 2009; McMain 2017; Mousavi 2015; Naidoo 2014; Owens 2020;
it was not clear what scale was used to assess depression (Torhorst Priebe 2012; Sahin 2018; Salkovskis 1990; Slee 2008; Sreedaran
1987; Torhorst 1988). 2020; Stewart 2009; Tapolaa 2010; Torhorst 1987; Walton 2020;
Weinberg 2006). In the remaining trials, a variety of sources were
Hopelessness used to ascertain suicide, including: Coroner's records (Allard 1992;
Hopelessness was assessed using the BHS in the majority (80.9%) Amadéo 2015; Hatcher 2011; Hatcher 2015; Hatcher 2016; Hvid
of the 21 trials that reported information on this outcome (Brown 2011; Tyrer 2003), mortality registers (Carter 2005; Cedereke 2002;
2005; Grimholt 2015; Hatcher 2011; Hatcher 2015; Hatcher 2016; Hassanian-Moghaddam 2011; Kawanishi 2014; Morthorst 2012;
Husain 2014; Kawanishi 2014; Lin 2020; Linehan 1991; McAuliffe Mouaffak 2015; O'Connor 2017; Van Heeringen 1995), mortality
2014; McLeavey 1994; Patsiokas 1985; Salkovskis 1990; Stewart statistics supplemented by Coroner’s records (Evans 1999a),
2009; Van der Sande 1997; Waterhouse 1990; Wang 2016), by the hospital records (McAuliffe 2014), medical records (Van der Sande
future optimism subscale score on the Reasons for Living Inventory 1997), hospital and/or medical records supplemented by Coroner’s
(RFL; Osman 1992), which was reverse coded in the present review records (Vaiva 2006; Vaiva 2018), or from collateral informant report
to indicate a perceived lack of optimism about the future in three (Crawford 2010; Fleischmann 2008; Hawton 1987; Wei 2013).
trials (Linehan 2015; O'Connor 2015; O'Connor 2020), and by an Excluded studies
idiosyncratic scale in one trial (Mousavi 2017).
A total of 157 studies were excluded from this update. The most
General functioning common reason for exclusion was that not all trial participants had
General functioning was assessed using the Global Assessment engaged in SH within six months of trial entry (90 studies). Reasons
Scale (GAS; Endicott 1976) in the majority (66.7%) of the six trials for exclusion for the remaining studies are shown in Figure 1.
that reported information on this outcome (Allard 1992; Andreoli
Details on the reasons for exclusion for those trials related to
2015; Bateman 2009; Tyrer 2003), followed by the GAF in the
psychosocial interventions for SH in adults identified by this update
remaining two trials (Cedereke 2002; Sahin 2018).
are reported in the Characteristics of excluded studies section.

Informed decisions.
Ongoing studies Studies awaiting classification

Of the 20 ongoing studies identified in the previous version of Two potentially eligible trials could not be included in this review
this review (Hawton 2016), seven were included in this update (NCT00533117; NCT00834834). Whilst results from these trials have
(Brown 2005; Lin 2020; O'Connor 2015; O'Connor 2017; O'Connor been posted online, we were unable to confirm whether they met
2020; Owens 2020; Vaiva 2018). Ten were excluded: for three, trial our inclusion criteria with the trial authors. Further information
results were unavailable, for two, trial registration subsequently is provided in the Characteristics of studies awaiting classification
lapsed, two were suspended due to feasibility difficulties, two section.
subsequently included participants who had not engaged in SH,
and one was subsequently published as a qualitative report. Risk of bias in included studies
A total of 25 ongoing studies were identified in this update (see Risk of bias was evaluated for the primary outcome repetition of SH
Characteristics of ongoing studies section for further information). at post-intervention. The results of the 'Risk of bias' assessments
can be seen in Figure 2 and Figure 3. Full 'Risk of bias' assessments,
including the evidence we used to justify our ratings, are available
here: doi.org/10.6084/m9.figshare.14159244.
Figure 2. Summary of 'Risk of bias' assessments

Informed decisions.
Figure 3. Results of 'Risk of bias' assessments for each study

Informed decisions.
Figure 3. (Continued)
Bias arising from randomisation process domain as no deviations from the intended intervention were
apparent and analyses were conducted on an intention-to-treat
All trials used random allocation to assign participants to the
(ITT) basis, although the statistical method(s) used to undertake
intervention and comparator arms. Most trials (98.7%) randomised
these analyses were not always clearly reported. Twenty-one
at the individual level. In one trial, cluster randomisation was used
trials were rated as having some concerns for this domain. For
(Bennewith 2002). Over half (55.3%) were rated as having a low risk
the majority of these, there was insufficient information on the
of bias for this domain. Thirty (39.5%) trials were rated as having
analyses method(s) used (Dubois 1999; Evans 1999b; Fleischmann
some concerns for this domain. For most of these, insufficient
2008; Gibbons 1978; Gratz 2006; Hawton 1981; Liberman 1981;
detail on either generation of the randomisation sequence and/
Linehan 1991; Linehan 2006; McAuliffe 2014; McLeavey 1994;
or allocation concealment was reported (Allard 1992; Amadéo
Mousavi 2015; Mousavi 2017; O'Connor 2015; Patsiokas 1985;
2015; Brown 2005; Cedereke 2002; Dubois 1999; Gratz 2006; Gratz
Sreedaran 2020; Torhorst 1987; Torhorst 1988; Waterhouse 1990;
2014; Kapur 2013; Liberman 1981; Linehan 2006; Marasinghe
Welu 1977). For one, some minor departures from the intended
2012; McLeavey 1994; Morgan 1993; Mousavi 2015; O'Connor 2020;
intervention occurred as a result of the experimental context.
Patsiokas 1985; Priebe 2012; Sahin 2018; Stewart 2009; Tapolaa
Specifically, some participants moved GP practices. However, as
2010; Turner 2000; Van Heeringen 1995; Wang 2016; Wei 2013). For
the proportion of participants who moved practices was small and
three further trials, baseline differences between the intervention
relatively balanced between the intervention and comparator arms
and comparator arms suggested there may have been a problem
in this trial, this was unlikely to have had a substantial impact on the
with the randomisation process (Carter 2005; Guthrie 2001; Hatcher
results observed (Bennewith 2002). Two trials were rated as being
2011), whilst for two older trials, information on characteristics of
at high risk of bias for this domain (Carter 2005; Naidoo 2014). In the
the intervention and comparator arms at baseline was not reported
first, some participants randomised to the control group mistakenly
(Waterhouse 1990; Welu 1977). Four (5.3%) trials were rated as
received the intervention treatment and whilst ITT analyses were
having high risk of bias for this domain due to insufficient detail
undertaken, the impact was not balanced between the intervention
on generation of the randomisation sequence and/or allocation
and comparator arms in this trial (Carter 2005). In the second, the
concealment coupled with significant differences between the
trial authors claimed the intervention was effective in preventing
intervention and control arms at baseline on one or more factors,
repeat SH even though there were major discrepancies in the data
suggesting there may have been a problem with the randomisation
presented in the original trial report that we, as review authors,
process in these trials (Davidson 2014; O'Connor 2015; Torhorst
were unable to clarify through correspondence (Naidoo 2014).
1987; Torhorst 1988).
Bias due to missing outcome data
Bias due to deviations from intended interventions
The majority of trials (82.9%) were at low risk of bias for this
Whilst participants and clinical personnel were, typically, not blind
domain as fewer than 5% of the data were missing at the post-
to allocation owing to likely differences in treatment intensity
intervention assessment or, the proportion of missing data was
between the intervention and comparator arms, most trials (69.9%)
balanced between the intervention and comparator arms at post-
were nonetheless rated as being at low risk of bias for this
intervention. However, there were some concerns with respect
Informed decisions.
to this domain for four (5.3%) trials. For two of these, no data we were unable to clarify through correspondence with the trial
on repetition of SH were reported (Patsiokas 1985; Sahin 2018). authors (Naidoo 2014). Finally, for two trials, no information on
For one, there was evidence of a larger proportion of missing repetition of SH was reported (Patsiokas 1985; Sreedaran 2020).
data for the comparator arm as compared to the intervention arm
(McAuliffe 2014), whilst, for one, the proportion of missing data Bias in selection of the reported result
was greater for the intervention arm (O'Connor 2015). None of Fourteen trials (18.4%) were rated as being at low risk of bias for
these trials undertook sensitivity analyses to investigate the impact this domain. Of these, only one clearly reported that data had
that missing data may have had on the estimate of treatment been analysed in accordance with a prespecified analysis plan that
effectiveness. had been finalised before unblinded outcome data and been made
available for analysis (Tyrer 2003), whilst for 13 further trials there
Nine (11.8%) trials were rated as being at high risk of bias for
had been no major departures from the analysis plan as outlined
this domain. For five of these, there was evidence of a difference
in either a published trial protocol (Linehan 2015) or clinical trials
in the proportion of missing data between the intervention and
register (Bateman 2009; Gysin-Maillart 2016; Harned 2014; Hatcher
comparator arms, no information on likely causes of missingness
2011; Hatcher 2015; Hatcher 2016; Husain 2014; McMain 2017;
was reported, and sensitivity analyses were not undertaken to
O'Connor 2017; O'Connor 2020; Owens 2020; Vaiva 2018), although
investigate the impact of missing data (Davidson 2014; Evans
it should be noted that one of these trials was retrospectively
1999b; Grimholt 2015; McLeavey 1994; Wei 2013). For one trial,
registered (Bateman 2009).
those with a repeat episode of SH during the follow-up period were
excluded from subsequent analyses (Sreedaran 2020); in another, Most trials (80.3%) were rated as having some concerns for this
data for over one-third (38.1%) of the randomised sample were domain. In the majority of cases, this was because trials were
not included in follow-up assessments (Linehan 1991). For another published prior to the International Committee of Medical Journal
trial, there were major discrepancies in the data presented in Editors' (ICMJE) requirement in 2015 that all trials be preregistered
the original trial report that we, as review authors, were unable in a publicly available clinical trials registry. It was, therefore,
to clarify through correspondence (Naidoo 2014). Finally, for one difficult to determine whether data had been analysed according
multisite and multi-country trial there was evidence of substantial to a prespecified plan, although there were no apparent departures
regional differences in missingness (Fleischmann 2008). from the analyses outlined in the methods section of these trials
(Armitage 2016; Amadéo 2015; Andreoli 2015; Mouaffak 2015;
Bias in measurement of the outcome
Mousavi 2015; Mousavi 2017; Sahin 2018; Walton 2020; Wang
There were some concerns regarding bias in the measurement of 2016). For five trials that were preregistered, this domain was
the outcome for just over one-fifth (21.1%) of the trials included also rated as having some concerns, as the information provided
in this review. Typically, this was because repetition of SH was within the clinical trials was not sufficiently detailed to determine
ascertained from self-reported information alone and participants whether there had been departures from the proposed analysis
were either not blind to treatment allocation and/or participant plan (Grimholt 2015; Kawanishi 2014; Lin 2020; McMain 2009;
blinding was unlikely to have been possible to achieve given O'Connor 2015). For two further trials, there were some concerns
the differences in therapeutic intensity between the intervention for this domain as data on repetition of SH for one or more
and comparator arms (Gratz 2014; Hassanian-Moghaddam 2011; eligible time point(s) were not reported (Naidoo 2014; Salkovskis
McAuliffe 2014; Mousavi 2017; O'Connor 2020; Priebe 2012; Slee 1990); however, in both of these trials, it was unlikely results
2008; Tapolaa 2010; Torhorst 1987; Torhorst 1988; Van Heeringen were selectively reported for favourability. Finally, for two trials,
1995; Walton 2020; Wei 2013; Weinberg 2006). For one trial, no information on repetition of SH was reported (Patsiokas 1985;
repetition of SH was ascertained from clinical personnel who were Sreedaran 2020).
not blind to treatment allocation (Waterhouse 1990), whilst in
another, repetition of SH was ascertained from unblinded clinical One trial was rated as being at high risk of bias for this domain
personnel for the majority of those allocated to the intervention as, although repetition of SH was a prespecified outcome, data
arm (Allard 1992). at post-intervention and at the 12-month follow-up assessment
were not reported due to a high proportion of missing outcome
Ten (13.2%) trials were rated as being at high risk of bias for data for these time points, although data at longer time points
this domain. For most of these, repetition of SH was ascertained were reported (Sahin 2018). Additionally, we were unable to obtain
from self-reported information alone, participant blinding was unpublished data for these time points despite correspondence.
unlikely to have been possible to achieve given the differences
in therapeutic intensity between the intervention and comparator Overall bias
arms, and assessment of the outcome could have been influenced As a consequence, most trials (84.2%) were rated as either having
by knowledge of the intervention received (Lin 2020; Linehan 1991; some concerns or being at high risk of bias.
O'Connor 2015; Sahin 2018; Turner 2000; Welu 1977). For one
trial, repetition of SH was obtained from self-report. Given that Effects of interventions
participants assigned to the intervention and comparator arms
in this trial received different treatment modalities (i.e. face-to- See: Summary of findings 1 Comparison 1.1: Individual-based
face versus telephone) and that previous work has shown that CBT-based psychotherapy compared to TAU or another comparator
participants may be less willing to report sensitive information for self-harm in adults; Summary of findings 2 Comparison
face-to-face than by telephone (Pridemore 2005), ascertainment 1.2: Group-based CBT-based psychotherapy compared to TAU
of the outcome could have differed between groups in this or another comparator for self-harm in adults; Summary of
trial (Mousavi 2015). For one further trial, there were major findings 3 Comparison 2.1: DBT compared to TAU or another
discrepancies for this outcome in the original trial report that comparator for self-harm in adults; Summary of findings 4

Informed decisions.
Comparison 2.2: DBT group-based skills training compared to Comparison 1.1: Individual cognitive behavioural therapy
TAU or another comparator for self-harm in adults; Summary (CBT)-based psychotherapy versus TAU or another comparator
of findings 5 Comparison 2.3: DBT individual therapy compared
For one trial (Stewart 2009), there were separate treatment arms
to TAU or another comparator for self-harm in adults; Summary
for CBT and PST. We therefore combined data from these two
of findings 6 Comparison 2.4: DBT prolonged exposure protocol
conditions, given their similarity. For one further trial (Wei 2013),
compared to TAU or another comparator for self-harm in adults;
there were two intervention arms: CBT-based psychotherapy and
Summary of findings 7 Comparison 3: MBT compared to TAU or
telephone contact. We therefore included only data for the CBT-
another comparator for self-harm in adults; Summary of findings
based psychotherapy arm.
8 Comparison 4: Emotion-regulation psychotherapy compared to
TAU or another comparator for self-harm in adults; Summary Primary outcome
of findings 9 Comparison 5: Psychodynamic psychotherapy
compared to TAU or another comparator for self-harm in adults; 1.1.1 Repetition of SH
Summary of findings 10 Comparison 6: Case management Four trials reported data on the proportion with a repeat episode
compared to TAU or another comparator for self-harm in adults; of SH by the post-intervention assessment (Mousavi 2017; Stewart
Summary of findings 11 Comparison 7: Structured GP follow- 2009; Wei 2013; Weinberg 2006). While there was imprecision in the
up compared to TAU or another comparator for self-harm in effect estimate, CBT-based psychotherapy may reduce repetition of
adults; Summary of findings 12 Comparison 9.1: Emergency SH by post-intervention (OR 0.35, 95% CI 0.12 to 1.02; participants
cards compared to TAU or another comparator for self-harm in = 238; studies = 4; I2 = 0%; Analysis 1.1). The overall risk of bias
adults; Summary of findings 13 Comparison 9.2: Coping cards was high for one trial (Wei 2013) and there were some concerns
compared to TAU or another comparator for self-harm in adults; for the remaining trials. According to GRADE criteria, we judged the
Summary of findings 14 Comparison 9.4: Postcards compared evidence to be of low certainty.
to TAU or another comparator for self-harm in adults; Summary
of findings 15 Comparison 9.5: Telephone contact compared to By the six-month follow-up assessment, on the basis of data from 12
TAU or another comparator for self-harm in adults; Summary of trials, there was evidence of an effect for CBT-based psychotherapy
findings 16 Comparison 9.6: Telephone contact, emergency cards, on repetition of SH (OR 0.52, 95% CI 0.38 to 0.70; N = 1260; k = 12; I2 =
and letters compared to TAU or another comparator for self-harm 2%; Analysis 1.2). For one trial (Owens 2020), data on self-reported
in adults; Summary of findings 17 Comparison 9.7: Telephone- SH were also reported. Using these data did not materially change
based psychotherapy compared to TAU or another comparator this result.
for self-harm in adults; Summary of findings 18 Comparison
10: Provision of information and support compared to TAU or There was also evidence of an effect for CBT-based psychotherapy
another comparator for self-harm in adults; Summary of findings by the 12-month follow-up assessment in nine trials (OR 0.81, 95%
19 Comparison 11: Other multimodal interventions compared to CI 0.66 to 0.99; N = 2458; k = 9; I2 = 0%; Analysis 1.3). One trial also
TAU or another comparator for self-harm in adults; Summary reported data for the consenting sample (i.e. including only those
of findings 20 Comparison 12.5: General hospital management participants who, following treatment allocation, subsequently
compared to TAU or another comparator for self-harm in adults; consented to participation), rather than all those randomised, as
Summary of findings 21 Comparison 12.8: Long-term therapy well as data on the proportion of participants self-reporting an
compared to TAU or another comparator for self-harm in adults episode of SH rather than those admitted to hospital following an
episode of SH, as well as data for the consenting sample (Hatcher
Comparison 1: Cognitive behavioural therapy (CBT)-based 2011). Using either source of data for this trial, however, did not
psychotherapy versus TAU or another comparator materially affect the overall result. Two trials reported data on
Twenty-one trials assessed the effectiveness of CBT-based repetition of SH by 24 months. An effect for this outcome was found
psychotherapy, in which participants in the intervention group (OR 0.31, 95% CI 0.14 to 0.69; N = 105; k = 2; I2 = 0%; Analysis 1.4).
were offered some form of specific psychological therapy such With respect to frequency of SH, data from four trials indicated no
as CBT or problem-solving therapy (PST), for adults (weighted effect for CBT-based psychotherapy on frequency of SH repetition
mean age: 31.7 ± 12.1 years; 56.7% female) presenting to services by the post-intervention assessment (MD -0.53, 95% CI -1.67 to 0.61;
following an episode of SH (Brown 2005, N = 120; Davidson 2014, N
participants = 149; studies = 4; I2 = 62% ; Analysis 1.5). However,
= 20; Dubois 1999, N = 102; Evans 1999b, N = 32; Gibbons 1978, N =
there was evidence of an effect for CBT-based psychotherapy by
400; Guthrie 2001, N = 119; Hatcher 2011, N = 1094; Hawton 1987,
the six-month assessment (MD -0.71, 95% CI -1.32 to -0.11; N =
N = 80; Husain 2014, N = 221; Lin 2020, N = 147; McAuliffe 2014, N
118; k = 4; I2 = 0%; Analysis 1.6). One trial reported information
= 433; Mousavi 2017, N = 60; Owens 2020, N = 62; Patsiokas 1985,
on median, rather than mean, number of episodes of SH at six
N = 15; Salkovskis 1990, N = 20; Slee 2008, N = 82; Stewart 2009, N
months. However, the authors found that although “[t]he rate of
= 32; Tapolaa 2010, N = 16; Tyrer 2003, N = 480; Wei 2013, N = 162;
self-harm episodes was lower in the [experimental] group...[it was
Weinberg 2006, N = 30).
not] significantly so” (Evans 1999b, pg.22).
In most trials, therapy was typically very brief (i.e. ≤ 10 sessions)
There was evidence of an effect for CBT-based psychotherapy by the
over a relatively brief period (i.e. median: three months; IQR: one
12-month assessment in a single trial (mean 1.18, SD 4.22, n = 40
to 3.7 months; range: one to 12 months), and was delivered on an
versus mean 4.58; SD 8.37; n = 33; MD -3.40, 95% CI -6.54 to -0.26;
individual basis in all but one (McAuliffe 2014).
N = 73; k = 1; I2 = not applicable; Slee 2008). A further trial reported
information on median number of episodes of SH at 12 months’
follow-up, finding that “[t]he median number of self-harm episodes

Informed decisions.
was two in both [the experimental and TAU] groups” (Tyrer 2003, Only two trials reported depression scores by the 24-month follow-
pg.972). up assessment; however, there was no evidence of an effect for CBT-
based psychotherapy by this time point (Analysis 1.11).
Three trials reported numeric data on time to SH repetition. There
was no evidence of an effect for CBT-based psychotherapy on 1.1.4 Hopelessness
time to SH repetition in these three trials (Analysis 1.7). Four There was evidence of an effect for CBT-based psychotherapy
trials reported narrative information on time to SH repetition. In on hopelessness scores at the post-intervention assessment in
one, authors reported "[t]he time till next parasuicide act...showed five trials (MD -2.99, 95% CI -3.91 to -2.07; N = 803; k = 5; I2 =
trends in favour of MACT compared with TAU although [it was 0%; Analysis 1.12). One further trial also reported information on
not] statistically significant" (Evans 1999b, pg.23), whilst in a hopelessness scores at post-intervention (Mousavi 2017); however,
second, trial authors reported "[i]n the experimental (treated) as an idiosyncratic scale was used in this trial, data could not be
group, the mean time to repeat was 9.3 months, while the mean included in this review.
time to repeated attempt for the subjects in the control group was
three months" (Salkovskis 1990, pg.874). However, trial authors There was also evidence of an effect on hopelessness scores by
in a third reported "Kaplan-Maier survival analysis indicated that the six-month follow-up assessment in two trials (MD -3.14, 95% CI
MACT effected no significant difference in time to repetition of -4.78 to -1.49; N = 315; k = 2; I2 = 0%; Analysis 1.13).
DSH (log-rank chi square = .88, df = 15, n.s.)" (Weinberg 2006,
pg.487). Finally, in a more recent trial, "time to repetition...showed Three trials reported data on hopelessness scores at 12 months,
a more complex pattern, with speedier initial repetition among again showing a evidence of an effect for CBT-based psychological
participants randomised to problem-solving therapy" (Owens therapy (MD -1.89, 95% CI -2.97 to -0.81; N = 539; k = 3; I2 = 16%;
2020, pg.9). Analysis 1.14). One further trial reported data on median (rather
than mean) BHS scores at six- and 12-months follow-up (Lin 2020).
Secondary outcomes
One trial reported data on hopelessness scores at 24 months
1.1.2 Treatment adherence
(Brown 2005). However, there was no evidence of an effect for CBT-
Data on treatment adherence was reported for both the based psychotherapy on hopelessness scores by this time point in
intervention and comparator arms in one trial in which an effect this trial (mean 6.07, SD 5.28, n = 45 versus mean 7.24, SD 6.35, n =
for CBT-based psychotherapy was found for the proportion of 40; MD -1.17, SD -3.67 to 1.33; N = 85; k = 1; I2 = not applicable).
participants who completed all 12 sessions of therapy during the
acute phase in addition to the three booster sessions (40/40 versus 1.1.5 General functioning
33/42; OR 22.97, 95% CI 1.29 to 409.37; N = 82; k = 1; I2 = not One trial reported data on general functioning scores by the six-
applicable; Slee 2008). month assessment. However, whilst there was no evidence of
a difference in mean scores on this measure between the CBT-
Five trials reported data on treatment adherence for the
based psychotherapy and TAU arms in this trial (i.e. 59.4 versus
intervention arm only (Brown 2005; Evans 1999b; Husain 2014; Lin
59.6), insufficient information was reported to enable imputation
2020; Owens 2020). Brown 2005 found that “participants in the
of missing SDs (Tyrer 2003).
cognitive therapy (CT) group participated in a mean (SD) of 8.92
(5.97) CT sessions (range 0-24). Thirty participants (50%) received 1.1.6 Social functioning
ten or more CT sessions” (pg.568). In Evans 1999b, five participants
in the intervention group did not have specific sessions of manual- One trial reported data on social functioning scores at post-
assisted cognitive-behaviour therapy (MACT) and received almost intervention and, whilst there was no evidence of a difference
all input from the booklet component of CBT alone. Overall, 17 of in mean scores on this measure between the CBT-based
the 18 participants in the experimental group received the booklets. psychotherapy and TAU arms in this trial (i.e. 2.3 versus 2.3),
Husain 2014 found that “more than half of the (intervention) group insufficient information was reported to enable imputation of
attended all six sessions (n = 56)” (pg.466). Lin 2020 found that missing SDs (Hawton 1987).
"only around one fourth participants [sic] completed the scheduled
Three trials reported data on social functioning by the six-month
intervention" (pg.697). Owens 2020 found that almost half (43.3%)
follow-up assessment (Evans 1999b; Hawton 1987; Tyrer 2003),
attended all treatment sessions.
however, for two of these trials insufficient information was
1.1.3 Depression reported to enable imputation of missing SDs (Hawton 1987; Tyrer
2003). For the remaining trial, there was evidence of an effect for
There was evidence of an effect for CBT-based psychotherapy on CBT-based psychological therapy on social functioning scores by
depression scores at the post-intervention assessment (SMD -0.28, this time point (mean 9.8, SD 4.9, n = 18 versus mean 13.1, SD 4.0, n
95% CI -0.54 to -0.02; N = 953; k = 4; I2 = 71%; Analysis 1.8). = 12; MD -3.30, 95% CI -6.50 to -0.10; N = 30; k = 1; I2 = not applicable;
Evans 1999b).
There was no evidence of an effect for CBT-based psychotherapy
on depression scores at the six-month assessment in eight trials One of these trials also reported data on social functioning scores
(Analysis 1.9); however, there was evidence of an effect by the 12- by the 12-month follow-up period. However, whilst those allocated
month assessment in seven trials (SMD -0.36, 95% CI -0.64 to -0.07; to CBT-based psychotherapy had lower mean scores (i.e. 1.7 versus
N = 1130; k = 7; I2 = 76%; Analysis 1.10). One trial reported data 2.1), once again insufficient information was reported to enable
on median (rather than mean) HDRS scores at six- and 12-months imputation of missing SDs (Hawton 1987).
follow-up (Lin 2020); however, no effect was found for CBT-based
psychotherapy in this trial for this outcome.

Informed decisions.
1.1.7 Suicidal ideation test for subgroup differences was not statistically significant for this
There was evidence of an effect for CBT-based psychotherapy in five outcome at this time point (Chi2 = 1.97, df = 1, p = 0.16).
trials at the post-intervention assessment (SMD -0.48, 95% CI -0.68 With regards to time to SH repetition, data from one of these trials
to -0.28; N = 718; k = 5; I2 = 20%; Analysis 1.15), and by the six-month suggested that, whilst there was no evidence of an effect in those
follow-up assessment in four trials (SMD -0.38, 95% CI -0.60 to -0.17; without a history of multiple episodes of SH prior to trial entry (HR
N = 353; k = 4; I2 = 0%; Analysis 1.16). 1.55, 95% CI 0.98 to 2.48; N = 135; k = 1; I2 = not applicable), CBT-
One trial reported information on suicidal ideation scores by 12 based psychotherapy was associated with an effect on time to SH
months; however, CBT-based psychotherapy was not associated repetition in those with a history of multiple episodes of SH (HR
with an effect by this time point in this trial (mean 3.70, SD 6.70, 0.58, 95% CI 0.36 to 0.94; N = 194; k = 1; I2 = not applicable) in this
n = 187 versus mean 4.80, SD 7.40, n = 231; MD -1.10, 95% CI -2.45 trial (Hatcher 2011).
to 0.25; N = 418; k = 1; I2 = not applicable; Hatcher 2011). One trial Sensitivity analyses
reported data on median (rather than mean) BSSI scores at six- and
12-months follow-up (Lin 2020); however, no effect was found for One trial used Zelen's design (Hatcher 2011). Omitting this trial
CBT-based psychotherapy in this trial for this outcome. did not materially affect results for CBT-based psychotherapy on
repetition of SH by the 12-month assessment, depression scores
Two trials reported information on the proportion of participants at the 12-month assessment, hopelessness scores by the post-
with suicidal ideation (Mousavi 2017; Wei 2013). At post- intervention or 12-month assessments, or suicidal ideation scores
intervention, data from both of these trials indicated no evidence of at post-intervention. However, omitting this trial did cause a
an effect for CBT-based psychotherapy. There was also no evidence reduction in the SMD for CBT-based psychotherapy on depression
of an effect by the six-month or 12-month follow-up assessments in scores by the post-intervention assessment and the estimate was
one of these trials (Analysis 1.17). However, it is notable that for one no longer statistically significant (SMD -0.19, 95% CI -0.40 to 0.02; N
of these trials (Wei 2013), results were reported on the basis of those = 313; k = 5; I2 = 54%).
randomised despite the fact that a self-reported measure was used,
and high levels of dropout were observed by the 12-month follow- Two analyses within this comparison were associated with
up assessment. As we were unable to confirm these numbers with substantial levels of heterogeneity (Analysis 1.10, I2 = 76%; Analysis
trial authors, results much be interpreted with caution. 1.17.1, I2 = 85%); however, analyses did not indicate any individual
study was associated with excessive influence for either of these
One trial reported data on BSSI scores, however, insufficient outcomes.
information was available to enable imputation of missing SDs
(Salkovskis 1990). One further trial reported data on the proportion Comparison 1.2: Group-based cognitive behavioural therapy
scoring above zero on the BSSI at the post-intervention, 6, 12, and (CBT)-based psychotherapy versus TAU or another comparator
24-month follow-up assessments (Brown 2005), however, as this
Primary outcome
was not based on clinically established cut-points, these data were
unable to be included in this review. 1.2.1 Repetition of SH
1.1.8 Suicide There was no evidence of an effect for CBT-based psychotherapy,

delivered in a group-based format, as compared to TAU by the post-
Sixteen trials reported data on suicide deaths during follow-up. intervention assessment in a single trial (23/171 versus 27/142;
There was no evidence of an effect for CBT-based psychotherapy on OR 0.66, 95% CI 0.36 to 1.21; N = 313; k = 1; I2 = not applicable).
suicides by final follow-up (i.e. up to 24 months) (Analysis 1.18). In According to GRADE criteria, we judged the evidence to be of
one trial, there was one death in the intervention arm that medical moderate certainty.
staff considered to be a suicide, although the coroner did not record
a suicide verdict in this case (Tyrer 2003). Including this death as a There was also no evidence of an effect for group-based CBT-
suicide did not materially change the overall result. based psychotherapy on repetition of SH by the six-month follow-
up assessment (39/128 versus 26/106; OR 1.35, 95% CI 0.75 to 2.41;
Subgroup analyses N = 234; k = 1; I2 = not applicable), or by the 12-month follow-up
Two further trials reported data on repetition of SH by repeater assessment (54/222 versus 50/211; OR 1.03, 95% CI 0.67 to 1.61; N
status (Hatcher 2011; Lin 2020). There was no evidence of an effect = 433; k = 1; I2 = not applicable).
for CBT-based psychotherapy on repetition of SH by the six-month
There was also no evidence of an effect for group-based CBT-based
follow-up assessment for either those with a history of repeated
psychotherapy on frequency of SH repetition by the 12-month
SH (7/39 versus 16/49; OR 0.45, 95% CI 0.16 to 1.24; N = 88; k = 1;
follow-up assessment in this trial (mean 0.43, SD 1.23, n = 222 versus
I2 = not applicable; Lin 2020), or those without this history (3/33
mean 0.49, SD 1.53, n = 211; MD -0.06, 95% CI -0.32 to 0.20; N = 433;
versus 7/26; OR 0.27, 95% CI 0.06 to 1.18; N = 59; k = 1; I2 = not
n = 1; I2 = not applicable).
applicable; Lin 2020) in one trial. However, by the 12-month follow-
up assessment, data from these two trials indicated that whilst Secondary outcomes
CBT-based psychotherapy was not associated with an effect on
repetition of SH for those without a history of SH prior to trial entry 1.2.2 Treatment adherence
(Analysis 1.19), there was evidence of an effect on this outcome for Data on treatment adherence was reported for the intervention
those with a history of multiple episodes of SH (OR 0.56, 95% CI arm only. The authors found that “almost half of those assigned
0.36 to 0.88; N = 508; k = 1; I2 = 0%; Analysis 1.19). However, the to [problem-solving therapy] (103, 46.4%) attended all 6 therapy
sessions” (McAuliffe 2014, pg.4).

Informed decisions.
1.2.3 Depression For one of these trials, there were two different intervention arms:
There was no evidence of an effect for group-based CBT-based psychodynamic psychotherapy and DBT (Sahin 2018). We therefore
psychotherapy on depression by either the post-intervention included only data for the DBT arm. For a second of these trials,
(mean 18.20, SD 14.80, n = 171 versus mean 20.60, SD 16.00, n = 142; comparison was made between two different forms of DBT: DBT
MD -0.16, 95% CI -0.38 to 0.07; N = 313; k = 1; I2 = not applicable) or group-based skills training only (DBT-S; Linehan 2015a) and DBT
the six-month follow-up assessment (mean 17.30, SD 15.90, n = 128 individual therapy only (DBT-I; Linehan 2015b).
versus mean 19.40, SD 17.00, n = 106; MD -0.13, 95% CI -0.39 to 0.13; Comparison 2.1: Standard DBT
N = 234; k = 1; I2 = not applicable).
Primary outcome
1.2.4 Hopelessness
2.1.1 Repetition of SH
There was also no evidence of an effect for group-based CBT-based
psychotherapy on hopelessness scores at the post-intervention Overall, there was no evidence of an effect for standard DBT
(mean 6.50, SD 6.10, n = 171 versus mean 7.30, SD 6.20, n = 142; MD compared to either TAU or alternative psychotherapy in terms of
-0.80, 95% CI -2.17 to 0.57; N = 313; k = 1; I2 = not applicable) or six- the proportion of patients repeating SH by the post-intervention
month follow-up assessment (mean 6.80, SD 6.30, n = 128 versus assessment (OR 0.71, 95% CI 0.32 to 1.55; participants = 502; studies
mean 7.10, SD 6.10, n = 106; MD -0.30, 95% CI -1.89 to 1.29; N = 234; = 6; I2 = 60%; (Analysis 2.1). There was also no difference by
k = 1; I2 = not applicable). comparator (i.e. TAU versus alternative psychotherapy). The overall
risk of bias was high for two trials (Linehan 1991; Turner 2000) and
1.2.5 General functioning there were some concerns for the remaining trials. According to
GRADE criteria, we judged the evidence to be of very low certainty.
No data available.
1.2.6 Social functioning

There was also no evidence of an effect for DBT on repetition of
SH by the 12-month (OR 0.65, 95% CI 0.24 to 1.72; participants =
No data available. 269; studies = 3; I2 = 47%; Analysis 2.2) assessment. Once again,
there was no difference by comparator (i.e. TAU versus alternative
1.2.7 Suicidal ideation
psychotherapy).
There was no evidence of an effect for group-based CBT-based
psychotherapy on suicidal ideation by either the post-intervention DBT was associated with an effect for frequency of repeated SH by
(mean 4.30, SD 8.00, n = 171 versus mean 5.80, SD 9.70, n = 142; MD the post-intervention assessment when compared to either TAU or
-1.50, 95% CI -3.50 to 0.50; N = 313; k = 1; I2 = not applicable) or the alterative psychotherapy (MD -5.00, 95% CI -8.92 to -1.08; N = 659;
six-month follow-up assessment (mean 4.70, SD 8.90, n = 128 versus k = 7; I2 = 49%; Analysis 2.3). However, this effect was no longer
mean 4.90, SD 8.90, n = 106; MD -0.20, 95% CI -2.49 to 2.09; N = 234; found by the six-month follow-up assessment in one trial (mean
k = 1; I2 = not applicable). 0.32, SD 1.27, n = 42 versus mean 1.14, SD 3.94, n = 42; MD -0.82,
95% CI -2.07 to 0.43; N = 84; k = 1; I2 = not applicable; McMain 2017).
1.2.8 Suicide Following a 'naturalistic' follow-up period, data from one further
There was no evidence of an effect for group-based CBT-based trial indicated that the effectiveness of DBT in terms of frequency of
psychotherapy on suicide deaths by the final follow-up assessment SH was maintained at 24 months in this trial; however, this outcome
(1/222 versus 2/211; OR 0.47, 95% CI 0.04 to 5.25; N = 433; k = 1; I2 was only investigated for a proportion of the original participants
= not applicable). (61.9%) who the researchers were able to contact at 24 months
(Linehan 1991). Results have therefore not been reproduced in this
Subgroup analyses review.
Randomisation was stratified by both sex and repeater status in One trial reported information on time to repetition of SH,
this trial (McAuliffe 2014). However, we were unable to obtain data finding that those "receiving DBT were half as likely to make
disaggregated by either factor from the trial authors. a suicide attempt (hazard ratio, 2.66; P = .005)" (Linehan 2006,
pg.757). However, insufficient information was reported to enable
Sensitivity analyses calculation of the accompanying CIs for this outcome for this trial.
Not applicable.
Secondary outcomes
Comparison 2: Dialectical behavioural therapy (DBT) versus 2.1.2 Treatment adherence
TAU or another comparator
There was no evidence of an effect for DBT compared with
Ten trials investigated the effectiveness of dialectical behaviour either TAU or alternative psychotherapy for the proportion of
therapy (DBT) as compared to either TAU (Linehan 1991, N = 63; participants who completed treatment (Analysis 2.4). There was
McMain 2009, N = 180; McMain 2017, N = 84; Priebe 2012, N = 80; also no evidence of a difference by comparator. Two further trials
Sahin 2018, N = 50) or other forms of alternative psychotherapy did not report information on the proportion completing treatment
(Harned 2014, N = 26; Linehan 2006, N = 101; Linehan 2015, N = 99; in the comparator arm (McMain 2017; Priebe 2012), although the
Turner 2000, N = 24; Walton 2020, N = 166) in adults (weighted mean comparator in the former trial was a waiting-list control condition.
age: 27.5 ± 11.3 years; 89.7% female) diagnosed with a personality We were, therefore, unable to incorporate these results in a meta-
disorder, typically borderline personality disorder, and who were analysis.
receiving treatment from outpatient mental health services due to
recurrent SH.

Informed decisions.
2.1.3 Depression intervention assessment for females (21/38 versus 33/50; OR 0.64,
There was evidence of an effect for DBT compared to both 95% CI 0.27 to 1.52; N = 88; k = 1; I2 = not applicable), DBT may be
TAU or alternative psychotherapy on depression scores at post- associated with a greater proportion of males engaging in a repeat
intervention (SMD -0.37, 95% CI -0.58 to -0.17; N = 557; k = 6; I2 = 23%; episode of SH at this time point (12/13 versus 6/13; OR 14.00, 95%
Analysis 2.5). There was no evidence of a difference by comparator. CI 1.39 to 141.49; N = 26; k = 1; I2 = not applicable).
One trial also measured depression scores at post-intervention With regards to frequency of SH repetition, data obtained by
using the HRSD; however, there was no evidence of an effect for DBT correspondence for this trial indicated that, whilst DBT was
according to this measure in this trial (mean 7.50, SD 5.96, n = 12 associated with an effect at post-intervention for females (mean
versus mean 12.58, SD 3.90, n = 12; MD -5.08, 95% CI -9.11 to -1.05; 5.08, SD 11.13, n = 38 versus mean 17.66, SD 33.10, n = 50; MD -12.58,
N = 24; k = 1; I2 = not applicable; Turner 2000). 95% CI -22.41 to -2.75; N = 88; k = 1; I2 = not applicable), there was
There was no evidence of an effect for DBT on depression scores no evidence of an effect for males (mean 5.77, SD 5.34, n = 13 versus
by the six-month follow-up assessment in one trial (mean 27.94, SD mean 4.93, SD 7.24, n = 13; MD 0.84, 95% CI -4.05 to 5.73; N = 26; k
16.08, n = 42 versus mean 29.50, SD 15.71, n = 42; MD -1.56, 95% CI = 1; I2 = not applicable).
-8.36 to 5.24; N = 84; k = 1; I2 = not applicable; McMain 2017) or by the There was no evidence of an effect for DBT as compared to
12-month follow-up assessment in one further trial (mean 12.60, SD alternative psychotherapy on the proportion of males (9/19 versus
6.80, n = 46 versus mean 14.40, SD 9.10, n = 35; MD -1.80, 95% CI 11/18; OR 0.57, 95% CI 0.15 to 2.12; N = 37; k = 1; I2 = not applicable)
-5.40 to 1.80; N = 81; k = 1; I2 = not applicable; Linehan 2006). or females (35/62 versus 37/63; OR 0.91, 95% CI 0.45 to 1.85; N = 125;
2.1.4 Hopelessness k = 1; I2 = not applicable) who completed the full course of treatment
on this trial.
We obtained data on hopelessness by correspondence for one trial
(Linehan 1991); however, there was no evidence of an effect for DBT Finally, whilst DBT was associated with an effect on depression
as compared to TAU by the 24-month follow-up assessment in this scores as compared to alternative psychotherapy at the post-
trial (mean 10.86, SD 6.04, n = 7 versus mean 10.69, SD 6.18, n = 11; intervention assessment for males (mean 13.54, SD 12.82, n = 13
MD 0.17, 95% CI -5.61 to 5.95; N = 18; k = 1; I2 = not applicable). versus mean 23.70, SD 12.30, n = 12; MD -10.16, 95% CI -20.01 to
-0.31; N = 25; k = 1; I2 = not applicable), there was no evidence of an
2.1.5 General functioning effect on depression scores for females in this trial (mean 15.34, SD
No data available. 14.01, n = 37 versus mean 21.88, SD 19.00, n = 48; MD -6.54, 95% CI
-13.56 to 0.48; N = 85; I2 = not applicable).
Sensitivity analyses
One trial reported data on social functioning scores at post-
intervention and by the six-month follow-up assessment (McMain Not applicable.
2017). Whilst there was evidence of an effect for DBT on social
functioning scores at post-intervention in this trial (mean 2.50, SD Comparison 2.2: DBT group-based skills training
0.56, n = 42 versus mean 2.88, SD 0.59, n = 42; MD -0.38, 95% CI -0.63 For one trial (i.e. Linehan 2015), there were two different
to -0.13; N = 84; k = 1; I2 = not applicable), this effect was no longer intervention arms: DBT group-based skills training only (DBT-S;
apparent by the six-month follow-up assessment (mean 2.60, SD Linehan 2015a) and DBT individual therapy only (DBT-I; Linehan
0.70, n = 42 versus mean 2.87, SD 0.65, n = 42; MD -0.27, 95% CI -0.56 2015b). For a detailed description of the therapeutic content of
to 0.02; N = 84; k = 1; I2 = not applicable). the two different intervention arms included in this trial, see the
Characteristics of included studies section.
There was no evidence of an effect for DBT when compared either Here we included results for DBT group-based skills training only as
to TAU or to alternative psychotherapy on suicidal ideation scores compared with standard DBT in adult women (mean age: 30.4 ± 7.5
at the post-intervention assessment in three trials (Analysis 2.6), or years) diagnosed with borderline personality disorder referred for
by the 12-month assessment in one of these trials (mean 24.10, SD outpatient treatment for repeated SH (Linehan 2015a, N = 66).
19.80, n = 46 versus mean 31.92, SD 26.80, n = 35; MD -7.80, 95% CI
Primary outcome
-18.38 to 2.74; N = 81; k = 1; I2 = not applicable; Linehan 2006). There
was also no evidence of a difference by comparator. 2.2.1 Repetition of SH
2.1.8 Suicide In this trial, data on repetition of SH were reported separately

for episodes of attempted suicide and NSSI. As we were unable
There was no evidence of an effect for DBT as compared to either to obtain data on combined SH from the trial authors despite
TAU or alternative psychotherapy on suicide deaths at either post- correspondence, we have reproduced the results for attempted
intervention (Analysis 2.7), the 12-month (Analysis 2.8), or 24- suicide and NSSI separately.
month follow-up period (Analysis 2.9).
There was no evidence of an effect for DBT group-based skills
Subgroup analyses training only as compared with standard DBT on suicide reattempts
Randomisation was stratified by sex in one trial (Walton 2020). (9/33 versus 12/33; OR 0.66, 95% CI 0.23 to 1.86; N = 66; k = 1; I2 = not
Whilst data obtained by correspondence from the trial authors applicable) or NSSI (18/33 versus 19/33; OR 0.88, 95% CI 0.33 to 2.34;
indicated that, compared with alternative psychotherapy, DBT was N = 66; k = 1; I2 = not applicable) at post-intervention. According to
not associated with an effect on repetition of SH by the post- GRADE criteria, we judged the evidence to be of moderate certainty.

Informed decisions.
There was also no evidence of an effect for DBT group-based skills 2.2.5 General functioning
training only on suicide reattempts (6/33 versus 2/33; OR 3.44, 95% No data available.
CI 0.64 to 18.51; N = 66; k = 1; I2 = not applicable) or NSSI (15/33
versus 15/33; OR 1.00, 95% CI 0.38 to 2.64; N = 66; k = 1; I2 = not 2.2.6 Social functioning
applicable) by the 12-month assessment in this trial.
No data available.
training only on frequency of suicide reattempts (mean 2.60, SD
2.90, n = 33 versus mean 3.40, SD 4.60, n = 33; MD -0.80, 95% CI There was no evidence of an effect for DBT group-based skills
-2.66 to 1.06; N = 66; k = 1; I2 = not applicable) or episodes of NSSI training, as compared with standard DBT, on suicidal ideation
(mean 9.90, SD 19.70, n = 33 versus mean 10.20, SD 16.30, n = 33; scores at either the post-intervention (mean 27.50, SD 19.10, n = 33
MD -0.30, 95% CI -9.02 to 8.42; N = 66; k = 1; I2 = not applicable) versus mean 32.00, SD 21.60, n = 33; MD -4.50, 95% CI -14.34 to 5.34;
at post-intervention. Nor was there any evidence of an effect for N = 66; k = 1; I2 = not applicable) or 12-month follow-up assessment
this intervention on frequency of suicide reattempts (mean 1.50, SD (mean 21.20, SD 19.20, n = 33 versus mean 28.90, SD 16.60, n = 33;
0.60, n = 33 versus mean 2.00, SD 1.40, n = 33; MD -0.50, 95% CI -1.02 MD -7.80, 95% CI -16.46 to 0.86; N = 66; k = 1; I2 = not applicable).
to 0.02; N = 66; k = 1; I2 = not applicable) or episodes of NSSI (mean
9.40, SD 20.40, n = 33 versus mean 7.90, SD 8.50, n = 33; MD 1.50, 95% 2.2.8 Suicide
CI -6.04 to 9.04; N = 66; k = 1; I2 = not applicable) by the 12-month There was one suicide death in the standard DBT arm by the
follow-up assessment in this trial. 24-month follow up assessment in this trial; however, there was
no evidence of an effect for DBT group-based skills training, as
Finally, with regards to time to SH repetition, "[s]urvival
compared with standard DBT, on this outcome by this time point
analysis...indicated no difference between groups in the time to the
(0/33 versus 1/33; OR 0.32, 95% CI 0.01 to 8.23; N = 66; k = 1; I2 = not
first suicide attempt (χ2 = 1.4 [P = .50])" (Linehan 2015, pg.4).
applicable).
Secondary outcomes
Subgroup analyses
No included trial stratified randomisation by sex or repeater status.
training, as compared with standard DBT, on the proportion of Sensitivity analyses
participants who completed treatment by the post-intervention Not applicable.
assessment in this trial (20/33 versus 25/33; OR 0.49, 95% CI 0.17 to
1.42; N = 66; k = 1; I2 = not applicable; Linehan 2015a). Comparison 2.3: DBT individual therapy
There was also no evidence of an effect for DBT group-based skills For one trial (i.e. Linehan 2015), there were two different
training, as compared with standard DBT, on the number of group intervention arms: DBT group-based skills training only (DBT-S;
therapy sessions attended (mean 4.20, SD 0.11, n = 33 versus mean Linehan 2015a) and DBT individual therapy only (DBT-I; Linehan
4.20, SD 0.12, n = 33; MD 0.00, 95% CI -0.06 to 0.06; N = 66; k = 2015b). For a detailed description of the therapeutic content of
1; I2 = not applicable; Linehan 2015a). Information on the number the two different intervention arms included in this trial, see the
of individual therapy sessions attended could not be estimated as Characteristics of included studies section.
individuals assigned to the group-based skills training arm in this
trial did not receive any individual therapy sessions. Here we included results for DBT individual therapy only as
compared with standard DBT in adult women (mean age: 30.6 ± 7.9
2.2.3 Depression years) diagnosed with borderline personality disorder referred for
outpatient treatment for repeated SH (Linehan 2015b, N = 66).
There was no evidence of a significant treatment effect for DBT
group-based skills training, as compared with standard DBT, on Primary outcome
depression scores at either the post-intervention (mean 10.40, SD
6.40, n = 33 versus mean 12.30, SD 8.00, n = 33; MD -1.90, 95% CI -5.40 2.3.1 Repetition of SH
to 1.60; N = 66; k = 1; I2 = not applicable), or 12-month assessment As before, in this trial, data on repetition of SH were reported
(mean 11.90, SD 8.80, n = 33 versus mean 15.20, 8.60, n = 33; MD separately for episodes of attempted suicide and NSSI. As we
-3.30, 95% CI -7.50 to 0.90; N = 66; k = 1; I2 = not applicable; Linehan were unable to obtain data on combined SH from the trial
2015a). authors despite correspondence, we have reproduced the results
for attempted suicide and NSSI separately.
2.2.4 Hopelessness
There was also no evidence of an effect for DBT group-based skills There was no evidence of an effect for DBT individual therapy
training, as compared with standard DBT, on hopelessness at either only as compared with standard DBT on suicide reattempts (15/33
the post-intervention (mean -155.30, SD 41.40, n = 33 versus mean versus 12/33; OR 1.46, 95% CI 0.54 to 3.91; N = 66; k = 1; I2 = not
-168.70, SD 45.3, n = 33; MD 13.40, 95% CI -7.54 to 34.34; N = 66; k applicable) or NSSI (21/33 versus 19/33; OR 1.29, 95% CI 0.48 to 3.47;
= 1; I2 = not applicable) or 12-month follow-up assessment (mean N = 66; k = 1; I2 = not applicable) at post-intervention. According
-152.20, SD 43.20, n = 33 versus mean -159.90, SD 40.20, n = 33; MD to the GRADE criteria, we judged the evidence to be of moderate
7.40, 95% CI -12.73 to 27.53; N = 66; k = 1; I2 = not applicable; Linehan certainty.
2015a) in this trial.
There was also no evidence of an effect for DBT individual therapy
only on suicide reattempts (7/33 versus 2/33; OR 4.17, 95% CI 0.80 to
Informed decisions.
21.85; N = 66; k = 1; I2 = not applicable) or NSSI (13/33 versus 15/33; 2.3.6 Social functioning
OR 0.78, 95% CI 0.29 to 2.07; N = 66; k = 1; I2 = not applicable) by the No data available.
12-month assessment in this trial.
There was no evidence of an effect for DBT individual therapy only
on frequency of suicide reattempts (mean 2.90, SD 3.00, n = 33 There was also no evidence of an effect for DBT individual therapy,
versus mean 3.40, SD 4.60, n = 33; MD -0.50, 95% CI -2.37 to 1.37; N as compared with standard DBT, on suicidal ideation scores at
= 66; k = 1; I2 = not applicable) or episodes of NSSI (mean 20.60, SD either the post-intervention (mean 30.30, SD 27.50, n = 33 versus
33.10, n = 33 versus mean 10.20, SD 16.30, n = 33; MD 10.40, 95% CI mean 32.00, SD 21.60, n = 33; MD -1.70, 95% CI -13.63 to 10.23; N
-2.19 to 22.99; N = 66; k = 1; I2 = not applicable) at post-intervention. = 66; k = 1; I2 = not applicable) or 12-month follow-up assessment
Nor was there any evidence of an effect for this intervention on (mean 25.50, SD 20.80, n = 33 versus mean 28.90, SD 16.60, n = 33;
frequency of suicide reattempts (mean 3.60, SD 3.20, n = 33 versus MD -3.40, 95% CI -12.48 to 5.68; N = 66; k = 1; I2 = not applicable).
mean 2.00, SD 1.40, n = 33; MD 1.60, 95% CI 0.41 to 2.79; N = 66; k
2.3.8 Suicide
= 1; I2 = not applicable) or episodes of NSSI (mean 16.00, SD 32.60,
n = 33 versus mean 7.90, SD 8.50, n = 33; MD 8.10, 95% CI -3.39 to There was one suicide death in the standard DBT arm by the
19.59; N = 66; k = 1; I2 = not applicable) by the 12-month follow-up 24-month follow-up assessment in this trial; however, there was
assessment in this trial. no evidence of an effect for DBT individual therapy only on this
outcome by this time point (0/33 versus 1/33; OR 0.32, 95% CI 0.01
Finally, with regards to time to SH repetition, "[s]urvival to 8.23; N = 66; k = 1; I2 = not applicable).
analysis...indicated no difference between groups in the time to the
first suicide attempt (χ2 = 1.4 [P = .50])" (Linehan 2015, pg.4). Subgroup analyses
Secondary outcomes No included trial stratified randomisation by sex or repeater status.
2.3.2 Treatment adherence Sensitivity analyses

There was evidence of an effect for DBT individual therapy, as Not applicable.
compared with standard DBT, on the proportion of participants who
completed treatment by the post-intervention assessment in this Comparison 2.4: DBT prolonged-exposure protocol
trial (17/33 versus 25/33; OR 0.34, 95% CI 0.12 to 0.97; N = 66; k = 1;
The effectiveness of two forms of DBT were compared over a three-
I2 = not applicable; Linehan 2015b).
month period in one small trial of adult (mean age: 32.6 ± 12.0
There was no evidence of an effect for DBT individual therapy, as years) women diagnosed with comorbid borderline personality
compared with standard DBT, on the number of individual therapy disorder and post-traumatic stress disorder and who were referred
sessions attended (mean 4.16, SD 0.18, n = 33 versus mean 4.20, SD to outpatient clinical services due to recurrent SH (Harned 2014,
0.18, n = 33; MD -0.04, 95% CI -0.13 to 0.05; N = 33; k = 1; I2 = not N = 26). In this trial, participants assigned to the intervention
applicable; Linehan 2015b). Information on the number of group arm received, in addition to the standard DBT protocol, additional
therapy sessions attended could not be estimated as participants weekly therapy sessions involving in vivo and imaginal exposure
assigned to the individual therapy arm in this trial did not receive to previously traumatic experiences (i.e. DBT prolonged-exposure
any group-based therapy sessions. protocol).
2.3.3 Depression Primary outcome
There was evidence of an increase in depression scores at post- 2.4.1 Repetition of SH

intervention for those receiving DBT individual therapy (mean Data obtained by correspondence indicated there was no evidence
18.20, SD 7.90, n = 33 versus mean 12.30, SD 8.00, n = 33; MD of an effect for the DBT prolonged-exposure protocol on repetition
5.90, 95% CI 2.06 to 9.74; N = 66; k = 1; I2 = not applicable). of SH by the post-intervention assessment (3/12 versus 2/6; OR
By the 12-month follow-up assessment, however, there was no 0.67, 95% CI 0.08 to 5.68; N = 18; k = 1; I2 = not applicable). According
longer evidence of an effect on depression scores for DBT individual to GRADE criteria, we judged the evidence to be of moderate
therapy, as compared with standard DBT in this trial (mean 13.90, certainty.
SD 9.60, n = 33 versus mean 15.20, 8.60, n = 33; MD -1.30, 95% CI
-5.70 to 3.10; N = 66; k = 1; I2 = not applicable). There was also no evidence of an effect for the DBT prolonged-
exposure protocol on repetition of SH by the six-month follow-up
2.3.4 Hopelessness assessment (3/12 versus 2/6; OR 0.67, 95% CI 0.08 to 5.68; N = 18; k
There was no evidence of an effect for DBT individual therapy, as = 1; I2 = not applicable).
compared with standard DBT, on hopelessness at either the post-
Data on frequency of SH, obtained following correspondence with
intervention (mean -177.90, SD 53.10, n = 33 versus mean -168.70,
trial authors, also suggested no effect for the DBT prolonged-
SD 45.30, n = 33; MD -9.20, 95% CI -33.01 to 14.61; N = 66; k = 1; I2 =
exposure protocol by either the post-intervention (mean 0.92, SD
not applicable), or 12-month follow-up assessment (mean -178.40,
1.97, n = 12 versus mean 1.17, SD 2.40, n = 6; MD -0.25, 95% CI -2.47
SD 53.70, n = 33 versus mean -159.90, SD 40.20, n = 33; MD -18.50,
to 1.97; N = 18; k = 1; I2 = not applicable) or six-month follow-up
95% CI -41.39 to 4.39; N = 66; k = 1; I2 = not applicable) in this trial.
assessments (mean 0.67, SD 1.50, n = 12 versus mean 0.33, SD 0.52,
2.3.5 General functioning n = 6; MD 0.34, 95% CI -0.61 to 1.29; N = 18; k = 1; I2 = not applicable).
No data available.

Informed decisions.
Secondary outcomes I2 = not applicable). According to GRADE criteria, we judged the

evidence to be of high certainty.
There was no evidence of an effect for the DBT prolonged-exposure There was also evidence of an effect for MBT on frequency of SH
protocol on the proportion of participants who completed the full episodes by the post-intervention assessment according to data
one-year course of treatment (10/17 versus 5/9; OR 1.14, 95% CI obtained by correspondence (mean 0.38, SD 0.38, n = 71 versus
0.22 to 5.84; N = 26; k = 1; I2 = not applicable). According to the trial mean 1.66, SD 2.87, n = 63; MD -1.28, 95% CI -2.01 to -0.55; N = 134;
authors, however, "...one therapist...was not adherent to DBT and k = 1; I2 = not applicable).
had a 100% dropout rate" (Harned 2014, p.12). Excluding the four
participants treated by this therapist did not, however, materially Secondary outcomes
affect this result. 3.2 Treatment adherence
2.4.3 Depression There was no evidence of an effect for MBT on the proportion of
participants who completed the full course of treatment (52/71
There was no evidence of an effect for the DBT prolonged-exposure versus 47/63; OR 0.93, 95% CI 0.43 to 2.02; N = 134; k = 1; I2 = not
protocol for depression scores at either the post-intervention applicable).
(mean 11.80, SD 8.00, n = 12 versus mean 15.50, SD 6.50, n = 6; MD
-3.70, 95% CI -10.59 to 3.19; N = 18; k = 1; I2 = not applicable) or six- 3.3 Depression
month follow-up (mean 12.50, SD 8.20, n = 12 versus mean 16.80,
MBT was associated with an effect for depression at the post-
SD 3.40, n = 6; MD -4.30, 95% CI -9.68 to 1.08; N = 18; k = 1; I2 = not
intervention assessment (mean 14.80, SD 8.55, n = 71 versus mean
applicable) assessments.
18.68, SD 8.76, n = 63, MD -3.88, 95% CI -6.82 to -0.94; N = 134; k =
2.4.4 Hopelessness 1; I2 = not applicable).
No data available. 3.4 Hopelessness
2.4.5 General functioning No data available.

No data available. 3.5 General functioning
2.4.6 Social functioning There was evidence of an effect for MBT on general functioning at
the post-intervention assessment (mean 60.9, SD 15.8, n = 71 versus
No data available. mean 53.2, SD 11.7, n = 63; MD 7.70, 95% CI 3.03 to 12.37; N = 134;
2.4.7 Suicidal ideation k = 1; I2 = not applicable).
No data available. 3.6 Social functioning
2.4.8 Suicide There was also evidence of an effect for MBT on social functioning at
the post-intervention assessment in this trial (mean 1.76, SD 0.50,
There was no evidence of an effect for the DBT prolonged-exposure n = 71 versus mean 2.17, SD 0.64, n = 63; MD -0.41, 95% CI -0.61 to
protocol on death by suicide by the follow-up assessment in this -0.21; N = 134; k = 1; I2 = not applicable).
trial (0/17 versus 1/9; OR 0.16, 95% CI 0.01 to 4.41, N = 26; k = 1; I2
= not applicable). 3.7 Suicidal ideation
Subgroup analyses No data available.
No included trial stratified randomisation by sex or repeater status. 3.8 Suicide
There were no suicides in either treatment arm by the time of the

post-intervention assessment.
Not applicable.
Subgroup analyses
Comparison 3: Mentalisation-based therapy (MBT) versus TAU
or another comparator
A single trial investigated the effectiveness of mentalisation-based Sensitivity analyses
therapy (MBT) in adults (mean age: 31.1 ± 7.7 years; 79.9% female) Not applicable.
diagnosed with BPD referred to a specialist personality disorder
treatment service following a suicide attempt or episode of life- Comparison 4: Emotion-regulation psychotherapy versus TAU
threatening SH (Bateman 2009, N = 134). or another comparator
Primary outcome Two trials investigated the effectiveness of emotion-regulation

psychotherapy, delivered in a group-based format, in adult women
3.1 Repetition of SH (weighted mean age: 33.2 ± 11.2 years) diagnosed with BPD referred
MBT may reduce repetition of SH by the conclusion of the 18-month for outpatient treatment as a result of recurrent SH (Gratz 2006, N
treatment period based on data obtained by correspondence = 22; Gratz 2014, N = 61).
(18/71 versus 31/63; OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1;

Informed decisions.
Primary outcome combined data from these two conditions given their similarity.
For the second trial, however, there were two different intervention
4.1 Repetition of SH
arms: psychodynamic psychotherapy and DBT (Sahin 2018).
Group-based emotion-regulation psychotherapy may reduce We therefore included here only data for the psychodynamic
repetition of SH by the post-intervention assessment based on psychotherapy arm.
evidence from two trials (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k =
2; I2 = 0%; Analysis 3.1). According to GRADE criteria, we judged the Primary outcome
evidence to be of moderate certainty. 5.1 Repetition of SH
There was no evidence of an effect for group-based emotion- There was no evidence of an effect for psychodynamic
regulation psychotherapy on frequency of repetition of SH by the psychotherapy by the post-intervention assessment in one of these
post-intervention assessment (Analysis 3.2). trials (9/140 versus 4/30; OR 0.45, 95% CI 0.13 to 1.56; N = 170; k = 1;
I2 = not applicable; Andreoli 2015). According to GRADE criteria, we
Secondary outcomes judged the evidence to be of moderate certainty.
4.2 Treatment adherence
This trial also reported information on time to repetition of SH,
No data available. finding that "participants who received either form of AP...had
increased survival to suicidal crisis relapse compared to patients
4.3 Depression assigned to TAU (AP-P vs. TAU log-rank test: Mantel χ2 = 7.63, df =
There was evidence of an effect for group-based emotion- 1, p = .006; AP-N vs. TAU log-rank test: Mantel χ2 = 9.87, df = 1, p
regulation therapy on depression scores at the post-intervention = .002)" (Andreoli 2015, pg.11).
assessment (MD -9.59, 95% CI -13.43 to -5.75; N = 83; k = 2; I2 = 0%;
Analysis 3.3). Secondary outcomes
4.4 Hopelessness
There was evidence of an effect for psychodynamic psychotherapy
No data available. on the proportion of participants who completed treatment by the
4.5 General functioning post-intervention assessment in one trial (131/140 versus 19/30; OR
8.43, 95% CI 3.09 to 22.99; N = 170; k = 1; I2 = not applicable; Andreoli
No data available. 2015).
4.6 Social functioning 5.3 Depression
No data available. There was evidence of an effect for psychodynamic psychotherapy
on depression scores at post-intervention in one trial (mean 9.90,
4.7 Suicidal ideation
SD 5.70, n = 140 versus mean 13.40, SD 6.40, n = 30; MD -3.50, 95%
No data available. CI -5.98 to -1.02; N = 170; k = 1; I2 = not applicable; Andreoli 2015).
4.8 Suicide 5.4 Hopelessness
There were no suicides in either the intervention or comparator No data available.

arms in either trial by the post-intervention assessment.
5.5 General functioning
Subgroup analyses There was also evidence of an effect for psychodynamic
Randomisation was stratified by repeater status in one trial (Gratz psychotherapy on general functioning scores by the post-
2014). However, we were unable to obtain disaggregated data from intervention assessment in one trial (mean 62.90, SD 6.20, n = 140
the trial authors despite correspondence. versus mean 57.6, SD 7.60, n = 30; MD 5.30, 95% CI 2.39 to 8.21; N =
170; k = 1; I2 = not applicable; Andreoli 2015).
5.6 Social functioning
Not applicable.
No data available.
Comparison 5: Psychodynamic psychotherapy versus TAU or
another comparator 5.7 Suicidal ideation
Two trials investigated psychodynamic psychotherapeutic One trial assessed suicidal ideation as the frequency of episodes
approaches as compared to TAU in adults (weighted mean age: 31.7 necessitating additional intensive psychiatric care (Andreoli 2015).
± 9.8 years; 88.9% female) who either presented to EDs following There was evidence of an effect for this intervention on frequency
an episode of SH or who were receiving outpatient treatment for of episodes of suicidal ideation scores at post-intervention in this
frequent repetition of SH (Andreoli 2015, N = 170; Sahin 2018, N = trial (mean 0.30, SD 0.60, n = 140 versus mean 1.00, SD 1.10, n = 30;
71). MD -0.70, 95% CI -1.11 to -0.29; N = 170; k = 1; I2 = not applicable;
Andreoli 2015).
For the first trial (Andreoli 2015), there were two separate
intervention arms: psychodynamic psychotherapy delivered either
by certified psychotherapists or trained nurses. We therefore

Informed decisions.
5.8 Suicide intervention" (Kawanishi 2014, pg.197). However, as corresponding

One participant died by suicide in the TAU arm in one trial by the numbers for the EUC group were not reported, we were unable
post-intervention assessment (0/140 versus 1/30; OR 0.07, 95% CI to analyse the effect of assertive case management on treatment
0.00 to 1.76; N = 170; k = 1; I2 = not applicable; Andreoli 2015). adherence for this trial.
Subgroup analyses Case management was associated with an effect on the proportion
of participants who completed treatment as compared with TAU by
No included trial stratified randomisation by sex or repeater status. the 12-month assessment in one trial (129/252 versus 102/256; OR
1.58, 95% CI 1.11 to 2.25; N = 508; k = 1; I2 = not applicable; Van
Sensitivity analyses Heeringen 1995).
Not applicable.
6.3 Depression
Comparison 6: Case management versus TAU or another No data available.
comparator
6.4 Hopelessness
Five trials investigated the provision of case management for the
prevention of SH compared either to TAU (Clarke 2002, N = 467; Hvid Although the BHS was administered to participants in one
2011, N = 133; Van Heeringen 1995, N = 516) or enhanced usual care trial (Kawanishi 2014), no data on this outcome was reported.
(EUC; Kawanishi 2014, N = 914; Morthorst 2012, N = 243) in adults Correspondence with trial authors for the previous version of this
(weighted mean age 37.9 ± 13.7 years; 56.2% female) admitted review indicated they were analysing these data to present in a
to hospital following an episode of SH. Although the intervention future report. However, data on this outcome has not been reported
in three of these trials included aspects of PST, this was not the in any of the secondary publications of this trial identified by this
primary or only element of the case management strategy (Hvid update of the review.
2011; Kawanishi 2014; Morthorst 2012). We therefore thought these
trials were sufficiently similar to the others to justify pooling within 6.5 General functioning
a meta-analysis. No data available.
Primary outcome 6.6 Social functioning
6.1 Repetition of SH No data available.
There was no evidence of an effect for case management on 6.7 Suicidal ideation
repetition of SH by the post-intervention assessment in four
of these trials, nor was there any evidence of a difference No data available.
by comparator (i.e. TAU versus EUC) (OR 0.78, 95% CI 0.47
6.8 Suicide
to 1.30; participants = 1608; studies = 4; I2 = 54%; Analysis
4.1). Supplementing hospital-recorded episodes of SH with self- There was no evidence of an effect for case management on suicide
reported data for Morthorst 2012 did not materially affect this by the post-intervention assessment, nor was there any evidence
result. Multiple readmissions for SH were, however, significantly of a significant difference by comparator for this outcome (Analysis
more common in the case management group than in the TAU 4.2). There was also no evidence of an effect for case management
group in one trial (9/220 versus 2/247; OR 5.23, 95% CI 1.12 to 24.45; on suicide by the 12-month follow-up assessment in one further
N = 467; k = 1; I2 = not applicable; Clarke 2002). According to GRADE trial (6/196 versus 7/195; OR 0.85, 95% CI 0.28 to 2.57; N = 391; k = 1;
criteria, we judged the evidence to be of low certainty. I2 = not applicable; Van Heeringen 1995).
There was also no evidence of an effect for case management as Subgroup analyses
compared with TAU on repetition of SH by the 12-month follow-up
One trial stratified randomisation by sex (Hvid 2011). Although
assessment in one further trial (21/196 versus 34/195; OR 0.57, 95%
there was no evidence of an effect in males in this trial (4/20 versus
CI 0.32 to 1.02; N = 391; k = 1; I2 = not applicable; Van Heeringen 4/18; OR 0.88, 95% CI 0.18 to 4.17; N = 38; k = 1; I2 = not applicable),
1995). case management was associated with an effect on repetition of SH
in females (2/49 versus 10/46; OR 0.15, 95% CI 0.03 to 0.74; N = 95;
Two trials provided information on time to SH repetition. In one,
k = 1; I2 = not applicable).
trial authors reported that "[t]he log-rank test shows a significant
difference in favour of fewer events in the intervention arm, log- A second trial stratified randomisation by repeater status
rank test 4.16 (P = 0.0414)" (Hvid 2011, pg.295). However, in the (Morthorst 2012). However, we were unable to obtain
second, trial authors reported "the survival curve for the assertive disaggregated data from the trial authors despite correspondence.
case management group was not significantly different from that
for the control group (log-rank P = 0.258, Wilcoxon P = 0·103)" Sensitivity analyses
Kawanishi 2014, pg.197).
Not applicable.
Secondary outcomes
Comparison 7: Structured general practitioner (GP) follow-up
6.2 Treatment adherence versus TAU or another comparator
The authors of one trial reported that "11 participants in A single trial investigated the effectiveness of structured follow-up
the assertive case management group did not receive the by the participants' general practitioner (GP) compared with TAU

Informed decisions.
over a six-month period in adults (mean age: 38.2 years, SD not CI -4.11 to 9.51; N = 13; k = 1; I2 = not applicable). Again, there were
reported; 74.5% female) admitted to the acute ward of a general substantial missing data for this outcome (136/149; 91.3%).
hospital following an episode of self-poisoning (Grimholt 2015, N =
202). 7.8 Suicide
There was one suicide death in each trial arm by the post-
Primary outcome intervention assessment. However, there was no evidence of
7.1 Repetition of SH an effect for structured GP follow-up by the post-intervention
assessment for this outcome (1/62 versus 1/87; OR 1.41, 95% CI 0.09
There was no evidence of an effect for structured GP follow-up on
to 22.98; N = 149; k = 1; I2 = not applicable).
the proportion repeating SH by the post-intervention assessment
according either to hospital records (8/60 versus 11/83; OR 1.01, Subgroup analyses
95% CI 0.38 to 2.68; N = 143; k = 1; I2 = not applicable) or emergency
medical records (9/54 versus 5/69; OR 2.56, 95% CI 0.80 to 8.15; N No included trial stratified randomisation by sex or repeater status.
= 123; k = 1; I2 = not applicable). According to GRADE criteria, we
judged the evidence to be of low certainty.
Not applicable.
The trial authors also reported data on self-reported repeat
episodes of self-poisoning, self-cutting, and other methods of SH. Comparison 8: Brief emergency department-based
Whilst a greater proportion of those assigned to structured GP interventions versus TAU or another comparator
follow-up reported repeat episodes of self-poisoning by the post-
intervention assessment (15/38 versus 9/57; OR 3.48, 95% CI 1.33 to Five trials investigated the effectiveness of a one-off brief
9.12; N = 95; k = 1; I2 = not applicable), there was no evidence of an (i.e. between 30 to 57 minutes' duration) intervention conducted in
effect for this intervention on self-reported episodes of self-cutting the emergency department (ED) in adults (weighted mean age 35.4
(10/40 versus 9/58; OR 1.81, 95% CI 0.66 to 4.98; N = 98; k = 1; I2 = not ± 13.5 years; 61.2% female) presenting to EDs following an episode
applicable) or other methods of SH (5/18 versus 9/17; OR 0.34, 95% of SH (Armitage 2016, N = 226; O'Connor 2015, N = 30; O'Connor
CI 0.08 to 1.39; N = 35; k = 1; I2 = not applicable) by this time point. 2017, N = 518; O'Connor 2020, N = 48).
Secondary outcomes Comparison 8.1: Brief Collaborative Assessment and

Management of Suicidality (CAMS)-based intervention
Two trials investigated the effectiveness of a brief intervention
There was no evidence of an effect for structured GP follow-up on informed by therapeutic principles of both the Collaborative
the proportion of participants who completed treatment by the Assessment and Management of Suicidality (CAMS) model, in which
post-intervention assessment in this trial (47/62 versus 64/87; OR a collaborative rapport is developed together with the participant,
1.13, 95% CI 0.53 to 2.39; N = 149; k = 1; I2 = not applicable). and the functional analysis model of DBT in which validation
and guided discovery is used to understand the participant's
7.3 Depression
motivations for SH, in adults (weighted mean age: 42.1 ± 8.7 years;
Although those allocated to the intervention arm in this trial 43.6% female) presenting to the ED following an episode of SH
had slightly higher depression scores by the post-intervention (O'Connor 2015, N = 30; O'Connor 2020, N = 48).
assessment, there was no evidence of an effect (mean 24.90, SD
10.10, n = 18 versus mean 18.80, SD 12.10, n = 22; MD 6.10, 95% CI Primary outcome
-0.78 to 12.98; N = 40; k = 1; I2 = not applicable); however, there were 8.1.1 Repetition of SH
substantial missing data for this outcome (109/149; 73.2%).
There was no evidence of an effect for brief CAMS and DBT-
7.4 Hopelessness based interventions on repetition of SH by the 12-month follow-up
assessment in one of these trials (1/13 versus 2/10; OR 0.33, 95% CI
There was also no evidence of an effect for structured GP follow-up
0.03 to 4.32; N = 23; k = 1; I2 = not applicable; O'Connor 2020).
on hopelessness scores by the post-intervention assessment in this
trial (mean 11.70; SD 5.60, n = 18 versus mean 8.70, SD 6.70, n = 26; One trial also reported data on frequency of repeat SH by the 12-
MD 3.00, 95% CI -0.65 to 6.65, N = 44; k = 1; I2 = not applicable). There month follow-up assessment which could be estimated from the
were, however, substantial missing data for this outcome (105/149; data reported. Once again, however, there was no evidence of an
70.5%). effect for a brief ED-based intervention on frequency of repeat SH
in this trial (mean 0.08, SD 0.28, n = 13 versus mean 1.30, SD 3.47, n
= 10; MD -1.22, 95% CI -3.38 to 0.94; N = 23; k = 1; I2 = not applicable;
No data available. O'Connor 2020).
7.6 Social functioning Secondary outcomes
No data available. 8.1.2 Treatment adherence
7.7 Suicidal ideation No data available.

There was no evidence of an effect for structured GP follow-up on 8.1.3 Depression
suicidal ideation scores by the post-intervention assessment (mean
19.80, SD 5.30, n = 6 versus mean 17.10, SD 7.20, n = 7; MD 2.70, 95% No data available.

Informed decisions.
8.1.4 Hopelessness responses that may help them to avoid SH (Armitage 2016, N = 151;
Data on hopelessness were available for both of these trials; O'Connor 2017, N = 518).
however, the trial authors did not report information on SDs or For one of these trials (Armitage 2016), there were two separate
other information to enable imputation of SDs. intervention arms: a guided implementation-focused intervention
By the six-month follow-up assessment, authors of one of these based on the volitional help-sheet model (Armitage 2016a), and
trials reported "[s]ignificant improvements across time on Reasons a self-directed implementation intention-focused intervention
for Living improvements were also observed for the [intervention] (Armitage 2016b). Given that the model used in Armitage 2016a was
group compared to the usual care group..." (O'Connor 2015, based in a large part on O'Connor 2017, and involved authors of
pg.431). However, data estimated from graphics presented in the this latter trial in the design of the intervention, we grouped these
trial report suggested any such difference was likely to be modest two trials within a single analysis. For a detailed description of the
(estimated mean -138.00, n = 11 versus estimated mean -136.50, n therapeutic content of the two different intervention arms included
= 13). in this trial, see the Characteristics of included studies section.
By the 12-month follow-up assessment, authors of the second Primary outcome

of these trials reported there were "no statistically significant 8.2.1 Repetition of SH
differences between groups on reported reasons for living...at any
There was no evidence of an effect for this intervention on
time point" (O'Connor 2020, pg.116).
repetition of SH by the six-month follow-up assessment in one of
8.1.5 General functioning these trials (72/259 versus 72/259; OR 1.00, 95% CI 0.68 to 1.47; N =
518; k = 1; I2 = not applicable; O'Connor 2017).
No data available.
One trial reported data on frequency of repeat SH episodes by the
six-month follow-up assessment; however, there was no evidence
No data available. of an effect for this intervention in this trial (mean 0.68, SD 2.53,
n = 259 versus mean 0.85, SD 2.78, n = 259; MD -0.17, 95% CI -0.63
8.1.7 Suicidal ideation to 0.29; N = 518; k = 1; I2 = not applicable; O'Connor 2017). For
Data on suicidal ideation scores were available for both of these the second of these trials (Armitage 2016a), data on frequency of
trials; however, the trial authors did not report information on SDs SH could not be disaggregated from data on frequency of suicidal
or other information to enable imputation of SDs. ideation and therefore could not be included in the review.
By the six-month assessment, authors of the first trial reported There was also no evidence of an effect for this intervention on time
"[a]lthough a trend was observed for greater improvement of to SH repetition in one of these trials (HR 0.80, 95% CI 0.55 to 1.18,
suicidal ideation for the TAU group..." (O'Connor 2015, pg.431), N = 518; k = 1; I2 = not applicable; O'Connor 2017).
this was not significant. Indeed, data estimated from graphics
Secondary outcomes
presented in the trial report suggested that suicidal ideation scores
were similar between the intervention and control arms by this 8.2.2 Treatment adherence
time point (estimated mean 7.00, n = 11 versus estimated mean
Data from one trial indicated that almost all (95.7%) of those
6.00, n = 13).
assigned to the intervention arm completed the intervention in the
For the second trial (O'Connor 2020), data estimated from graphics hospital. However, as corresponding numbers were not reported
presented in the trial report indicated there was no meaningful for the comparator arm in this trial, we could not calculate
difference in suicidal ideation scores by the 12-month follow- treatment effect sizes for this outcome (O'Connor 2017).
up assessment in this trial (estimated mean 5.50, n = 13 versus 8.2.3 Depression
estimated mean 5.30, n = 10).
One trial reported data on depression scores by the six-month
8.1.8 Suicide follow-up assessment (Armitage 2016a); however, there was no
No data available. evidence of an effect for this intervention (mean 16.65, SD 5.92, n =
75 versus mean 17.78, SD 6.51, n = 73; MD -1.13, 95% CI -3.14 to 0.88;
Subgroup analyses N = 148; k = 1; I2 = not applicable).
No included trial stratified randomisation by sex or repeater status. 8.2.4 Hopelessness
Sensitivity analyses No data available.
Not applicable. 8.2.5 General functioning
Comparison 8.2: Brief guided Integrated Motivational- No data available.

Volitional-focused intervention 8.2.6 Social functioning
Two trials investigated a guided intervention, based on the No data available.
Integrated Motivational-Volitional help-sheet model, in which
participants are encouraged to identify situations in which they 8.2.7 Suicidal ideation
may be triggered to engage in SH and link these with alternative
No data available.

Informed decisions.
8.2.8 Suicide Sensitivity analyses

There was no evidence of an effect for this intervention on suicide Not applicable.
deaths by the six-month follow-up in one trial (1/259 versus 2/259;
OR 0.50, 95% CI 0.04 to 5.53; N = 518; k = 1; I2 = not applicable; Comparison 8.4: Brief alcohol-focused intervention
O'Connor 2017).
One trial investigated the effectiveness of a brief ED-based
Subgroup analyses intervention for alcohol misuse on repetition of SH over a six-month
follow-up period in adults (mean age: 37.2 ± 12.0 years; 50.0%
No included trial stratified randomisation by sex or repeater status. female) who were misusing alcohol and were admitted to the ED
following an episode of SH (Crawford 2010, N = 103).
Not applicable. Primary outcome
Comparison 8.3: Brief self-guided Integrated Motivational-
Volitional-focused intervention There was no evidence of an effect for brief alcohol-focused ED-
based interventions on repetition of SH by the six-month follow-up
The second intervention arm in Armitage 2016 investigated the assessment in this trial (7/52 versus 11/51; OR 0.57, 95% CI 0.20 to
effectiveness of a self-guided intervention, based in the Integrated 1.60; k = 1; I2 = not applicable; Crawford 2010).
Motivational-Volitional help-sheet model, as compared to TAU in
adults (mean age: 29.3 ± 11.9 years; 69.9% female) presenting to Secondary outcomes
the emergency department following an episode of SH (Armitage
2016b, N = 151).
The trial authors reported that only around half (47.1%) of
Primary outcome those randomised to the intervention arm attended the brief
8.3.1 Repetition of SH alcohol treatment session (Crawford 2010, pg.1826). However, as
corresponding numbers were not available for those allocated to
For this trial, data on frequency of SH could not be disaggregated the control arm, who did not receive an invitation to brief alcohol
from data on frequency of suicidal ideation and therefore could not treatment sessions, we could not calculate treatment effect sizes
be included in the review. for this outcome.
Secondary outcomes 8.4.3 Depression
8.3.2 Treatment adherence No data available.
No data available. 8.4.4 Hopelessness
8.3.3 Depression No data available.
No effect for this intervention approach was found for depression 8.4.5 General functioning
scores by the six-month follow-up assessment in this trial (mean
16.20, SD 6.56, n = 78 versus mean 17.78, SD 6.51, n = 73; MD -1.58, No data available.
95% CI -3.67 to 0.51; N = 151; k = 1; I2 = not applicable; Armitage
2016b).
No data available.
8.3.4 Hopelessness
No data available.
No data available.
8.3.5 General functioning
8.4.8 Suicide
No data available.
Correspondence with trial authors confirmed that no participants
died by suicide in either arm over the course of the six-month
No data available. follow-up period. However, the authors warned that, as they were
unable to track participants via their National Health Service (NHS)
8.3.7 Suicidal ideation identity numbers, they were unable to confirm numbers of suicides
No data available. from national mortality data. Thus, there may have been suicide
deaths amongst those participants whom the authors were unable
8.3.8 Suicide to contact by the six-month follow-up assessment in this trial.
No data available. Subgroup analyses
Subgroup analyses No included trial stratified randomisation by sex or repeater status.
No included trial stratified randomisation by sex or repeater status. Sensitivity analyses
Not applicable.

Informed decisions.
Comparison 9: Remote contact interventions versus TAU or 9.1.4 Hopelessness

another comparator No data available.
A number of trials investigated the effectiveness of a variety
of remote contact interventions, including: emergency cards
(Evans 1999a; Morgan 1993), coping cards (Wang 2016), general No data available.
practitioners' (GP) letters (Bennewith 2002), postcards (Beautrais
2010; Carter 2005; Hassanian-Moghaddam 2011; Kapur 2013), 9.1.6 Social functioning
telephone contact (Cedereke 2002; Mousavi 2015; Vaiva 2006), No data available.
telephone contact combined with emergency cards and letters
(Mouaffak 2015; Vaiva 2018), and telephone-based psychotherapy 9.1.7 Suicidal ideation
(Marasinghe 2012; Sreedaran 2020; Wei 2013).
No data available.
Comparison 9.1: Emergency cards 9.1.8 Suicide
Two trials investigated the effectiveness of providing an emergency Data on suicides were reported in only one trial (Evans 1999a).
contact card ('green card') providing 24-hour access to emergency There was no evidence of an effect for emergency cards on suicide
advice from a psychiatrist in addition to TAU in adults (weighted by the post-intervention assessment in this trial (2/417 versus
mean age: 32.6 ± 11.7 years; 55.4% female) admitted to general 1/410; OR 1.97, 95% CI 0.18 to 21.82; N = 827; k = 1; I2 = not
hospitals following an episode of SH, most commonly self- applicable).
poisoning (Evans 1999a, N = 827; Morgan 1993, N = 212). Note,
repetition of SH data for Evans 1999a was reported in a secondary Subgroup analyses
publication (Evans 2005).
Data on repetition of SH was available by repeater status (i.e. those
Primary outcome without a history of multiple episodes of SH versus those with a
history of multiple episodes of SH) in one trial (Evans 1999a). There
was no evidence of an effect for emergency cards on repetition
There was no evidence of an effect for emergency cards on of SH in those without a history of multiple episodes of SH;
repetition of SH by the post-intervention assessment in these two however, emergency cards were associated with an increased risk
trials (OR 0.82, 95% CI 0.31 to 2.14; participants = 1039; studies = 2; of repetition of SH in those with a history of multiple episodes of SH
I2 = 68%; Analysis 5.1). According to GRADE criteria, we judged the by the 12-month follow-up assessment in this trial (Analysis 5.2).
evidence to be of low certainty.
For those without a history of multiple episodes of SH, there was no
There was also no evidence of an effect for emergency cards by the difference between groups in the number of participants who had
12-month follow-up assessment in the one trial for which data were none (203/221 versus 181/206; OR 1.56, 95% CI 0.82 to 2.95; N = 427;
available (Analysis 5.2). k = 1; I2 = not applicable), one (13/221 versus 16/206; OR 0.74, 95%
CI 0.35 to 1.58; N = 427; k = 1; I2 = not applicable), or two or more
One trial reported data on frequency of repetition of SH as the (5/221 versus 9/206; OR 0.51, 95% CI 0.17 to 1.54; N = 427; k = 1; I2 =
proportion of participants who had no episodes at follow-up, the not applicable) repeat episodes of SH (Evans 1999a).
proportion with a single episode at follow-up, and the proportion
with two or more repeat episodes of SH by the 12-month follow- For those with a history of multiple episodes of SH, however,
up assessment (Evans 1999a). There was no difference between receipt of an emergency card was associated with a reduction in
groups in the number of participants who had none (347/417 versus the number of participants with no further episodes of SH (142/194
351/410; OR 0.83, 95% CI 0.57 to 1.21; N = 827; k = 1; I2 = not versus 167/200; OR 0.54, 95%CI 0.33 to 0.88; N = 394; k = 1; I2 = not
applicable), one (46/417 versus 32/410; OR 1.46, 95% CI 0.91 to applicable) coupled with an increase in the number of participants
2.35; N = 827; k = 1; I2 = not applicable), or two or more (24/417 with one repeat episode of SH (33/194 versus 15/200; OR 2.53,
versus 27/410; OR 0.87, 95% CI 0.49 to 1.53; N = 827; k = 1; I2 = not 95% CI 1.33 to 4.82; N = 394; k = 1; I2 = not applicable). There
applicable) further episodes of SH. was no difference between the intervention and comparator groups
with respect to the number of participants with or two or more
One trial also reported information on time to SH repetition. The subsequent episodes of SH for those with a history of multiple
authors found that whilst "[t]he median time to first repeat among episodes of SH, however (19/194 versus 18/200; OR 1.10, 95% CI
those given a green card was 33 days (range 1-180); in the control 0.56 to 2.16; N = 394; k = 1; I2 = not applicable) (Evans 1999a).
group it was 40 days (range 2-156). This difference is not significant
(log rank test: chi-square 0.82, P = 0.36" (Evans 1999a, pg.25). Sensitivity analyses
Secondary outcomes Not applicable.
9.1.2 Treatment adherence Comparison 9.2: Coping cards

No data available. A single, small trial investigated the effectiveness of coping cards,
in which participants were encouraged to note down alternative
9.1.3 Depression activities they could engage in when feeling suicidal, resources they
No data available. found helpful when seeking help, as well as the numbers of a 24-
hour crisis line and local medical services, in addition to TAU as
compared to TAU alone in adults (mean age: 37.9±11.1 years; 73.4%

Informed decisions.
female) referred to a specialist suicide prevention service following As the trial authors were unable to provide values for either the
a suicide attempt (Wang 2016, N = 64). inter-cluster correlation coefficient or the design effect, and further,
there was no similar cluster RCT of this intervention approach from
Primary outcome which these values could be approximated, we were unable to
9.2.1 Repetition of SH statistically account for the effects of clustering. Results presented
in this section may therefore overestimate the effectiveness of this
There was no evidence of an effect for coping cards on the intervention.
proportion of participants re-attempting suicide by the post-
intervention assessment (0/32 versus 5/32; OR 0.08, 95% CI 0.00 to Primary outcome
1.45; N = 64; k = 1; I2 = not applicable; Wang 2016). According to
GRADE criteria, we judged the evidence to be of moderate certainty.
There was no evidence of an effect for a letter from participants' GPs
Regarding time to repetition, whilst numeric data were not on repetition of SH by the 12-month follow-up assessment in this
provided the authors report "[r]esults indicated that participants trial (211/964 versus 189/968; OR 1.15, 95% CI 0.93 to 1.44; N = 1932;
in the coping card group had a significantly longer time to re- k = 1; I2 = not applicable).
attempt than those in the TAU group...[at the] 3-month" (i.e., post-
intervention) period (Wang 2016, p.112). There was also no evidence of an effect for GP letters on time to SH
repetition in this trial (HR, 1.15, 95% CI 0.94 to 1.42; N = 1932; k = 1;
Secondary outcomes I2 = not applicable).
Secondary outcomes
No data available.
9.2.3 Depression There was no effect for the number of participants with a least
The authors indicate they measured depression; however, no data one contact with treatment services by the 12-month follow-up
on this outcome were reported in the trial report. assessment (351/599 versus 387/681; OR 1.08, 95% CI 0.86 to 1.34;
N = 1280; k = 1; I2 = not applicable).
9.2.4 Hopelessness
9.3.3 Depression
There was no evidence of an effect for coping cards on hopelessness
scores at post-intervention (mean 6.81, SD 2.98, n = 32 versus mean No data available.
8.38, SD 3.96, n = 32; MD -1.57, 95% CI -3.29 to 0.15; N = 64; k = 1; I2
9.3.4 Hopelessness
= not applicable; Wang 2016).
No data available.
No data available.
No data available.
No data available.
No data available.
Suicidal ideation was assessed in this trial; however, an
idiosyncratic six-point scale was used. Data on this outcome were No data available.
therefore unable to be included in this review.
9.3.8 Suicide
9.2.8 Suicide
No data available.
No data available.
Subgroup analyses
Subgroup analyses
Data on repetition of SH was available by sex and repeater status
No included trial stratified randomisation by sex or repeater status. (i.e. those without a history of multiple episodes of SH versus those
with a history of multiple episodes of SH). A post hoc analysis by
Sensitivity analyses sex suggested that whilst there was no effect for males (82/383
Not applicable. versus 84/413; OR 1.07, 95% CI 0.76 to 1.50; N = 796; k = 1; I2 = not
applicable), a GP letter was associated with an effect on repetition
Comparison 9.3: GP letters of SH for females (30/581 versus 105/555; OR 0.23, 95% CI 0.15 to
0.36; N = 1136; k = 1; I2 = not applicable).
A single cRCT compared the effectiveness of a letter from
participants' general practitioners following discharge from The trial authors also reported data on repetition of SH by repeater
hospital offering an appointment and advice compared to TAU status at trial entry and concluded that "[t]he odds ratio for
over a 12-month period in adults (mean age: 32.5 ± 13.2 years; the effect of the intervention in patients with a history of self-
59.0% female) presenting to hospital following an episode of SH harm was 0.57 (0.33 to 0.98), indicating a beneficial effect, and in
(Bennewith 2002, clusters = 98, N = 1932). those with no history was 1.32 (1.02 to 1.70), indicating a harmful

Informed decisions.
effect" (Bennewith 2002, pg.1258). However, as the raw data on 9.4.7 Suicidal ideation
which these subgroup results were based were not reported, we One trial reported information on suicidal ideation at both the
were unable to reproduce these results in this review. post-intervention assessment and 12- to 24-months' follow-up
Sensitivity analyses (Hassanian-Moghaddam 2011). There was an effect for postcards
on the proportion of participants reporting suicidal ideation at
Not applicable. the post-intervention assessment (302/1043 versus 446/1070; OR
0.57, 95% CI 0.48 to 0.68; N = 2113; k = 1; I2 = not applicable).
Comparison 9.4: Postcards Data reported by the same trial authors in a subsequent follow-up
Four trials assessed the effectiveness of sending postcards on a publication suggested that this effect was maintained by the 12- to
regular basis over a 12-month period to adults (weighted mean 24-month follow-up assessment (465/997 versus 588/1004; OR 0.62,
age: 27.1 ± 8.9 years; 63.0% female) presenting to hospital following 95% CI 0.52 to 0.74; N = 2001; k = 1; I2 = not applicable; Hassanian-
an episode of SH (Beautrais 2010, N = 327; Hassanian-Moghaddam Moghaddam 2017).
2011, N = 2113; Kapur 2013, N = 66), including one that used Zelen's
9.4.8 Suicide
design and reported data only for the randomised sample (Carter
2005, N = 772). There was no evidence of an effect for postcards on suicide by the
post-intervention assessment in these four trials (Analysis 6.6).
Primary outcome
Data on suicides by the 12-month follow-up assessment were
reported in one trial; however, no effect was found by this time
Overall, there was no evidence of an effect for postcards on point either (2/378 versus 5/394; OR 0.41, 95% CI 0.08 to 2.15; N =
the proportion of patients repeating SH by the post-intervention 772; k = 1; I2 = not applicable; Carter 2005).
assessment (OR 0.87, 95% CI 0.62 to 1.23; participants = 3277;
studies = 4; I2 = 51%; Analysis 6.1). According to GRADE criteria, we Subgroup analyses
judged the evidence to be of very low certainty. Randomisation was stratified by sex in one of these trials (Carter
2005); however, there was no evidence of an effect for postcards in
There was also no evidence of an effect for postcards on repetition
either sex at either the post-intervention (Analysis 6.1) or the the 12-
of SH by the 12-month follow-up assessment in two of these trials
month follow-up assessment (Analysis 6.2).
(Analysis 6.2).
Through correspondence, we were also able to obtain data on
With respect to frequency of SH, we obtained data on the mean
frequency of SH repetition by the post-intervention assessment
number of repeat SH episodes by correspondence for three of
by both sex and repeater status for three trials (Carter 2005;
the four trials of postcards (Carter 2005; Hassanian-Moghaddam
Hassanian-Moghaddam 2011; Kapur 2013). There was no evidence
2011; Kapur 2013). Overall, there was no evidence of an effect for
of an effect for postcards either by sex (test for subgroup
postcards on frequency of repeated SH by the post-intervention
differences: Chi2 = 0.07, df = 1, P = 0.79; Analysis 6.3) or by repeater
assessment in these three trials (Analysis 6.3). For the one
status (i.e. first SH episode versus repeat SH episode) (test for
remaining trial (Beautrais 2010), the available data indicated a
subgroup differences: Chi2 = 0.59, df = 1, P = 0.44; Analysis 6.3) in
reduced mean number of SH episodes for the intervention group
these trials. There was also no evidence of an effect for postcards
at post-intervention (0.57 versus 0.78); however, SDs were not
either by sex (test for subgroup differences: Chi2 = 1.25, df = 1,
presented and insufficient information was reported to enable
P = 0.26; Analysis 6.4) or by repeater status (test for subgroup
imputation of SDs. There was similarly no evidence of an effect
differences: Chi2 = 0.60, df = 1, P = 0.44; Analysis 6.4) by the 12-month
for postcards either by the 12-month follow-up assessment in two
follow-up assessment in two trials, or by the 24-month follow-up
trials (Analysis 6.4), or by the 24-month follow-up assessment in
period in one trial (sex: test for subgroup differences: Chi2 = 0.57, df
one trial (Analysis 6.5).
= 1, P = 0.45; repeater status: test for subgroup differences: Chi2 =
Secondary outcomes 0.35, df = 1, P = 0.55; Analysis 6.5).
9.4.2 Treatment adherence Sensitivity analyses

No data available. One trial used Zelen's design (Carter 2005). Omitting this trial
did not materially affect results for postcards on repetition of SH
9.4.3 Depression by the post-intervention assessment. However, by the 12-month
No data available. assessment, excluding this trial caused the result for repetition of
SH to become statistically significant (OR 0.67, 95% CI 0.52 to 0.86;
9.4.4 Hopelessness N = 2113; k = 1; I2 = not applicable). Additionally, excluding this trial
No data available. suggested a potentially harmful effect of postcards on suicides by
the post-intervention assessment (OR 3.74, 95% CI 1.04 to 13.51; N
9.4.5 General functioning = 2692; k = 3; I2 = 0%).
No data available. Four analyses within this comparison were associated with
substantial levels of heterogeneity (Analysis 6.4.1, I2 = 84%; Analysis
6.4.1, I2 = 84%; Analysis 6.4.3, I2 = 76%; Analysis 6.4.4, I2 =
No data available. 81%); however, analyses did not indicate any individual study was
associated with excessive influence for either of these outcomes.

Informed decisions.
Comparison 9.5: Telephone contact 9.5.7 Suicidal ideation
Three trials investigated the effectiveness of telephone contact Telephone contact was not associated with an effect on suicidal
in adults (weighted mean age: 36.5 ± 13.5 years; 72.1% female) ideation scores by the 12-month follow-up assessment in one trial
presenting to emergency departments following a suicide attempt (mean 5.80, SD 7.80, N = 5 versus mean 4.00, SD 6.20, N = 8; MD 1.80,
(Cedereke 2002, N = 216; Mousavi 2015, N = 55; Vaiva 2006, N = 605). 95% CI -6.27 to 9.87; N = 13; k = 1; I2 = not applicable; Cedereke 2002).
Primary outcome One further trial reported information on the proportion of

participants reporting suicidal ideation; however, once again
telephone contact was not associated with an effect by the post-
There was no evidence of an effect for telephone contact on intervention assessment in this trial (2/25 versus 1/22; OR 1.83, 95%
repetition of SH by the post-intervention in one trial (1/29 versus CI 0.15 to 21.64; N = 47; k = 1; I2 = not applicable; Mousavi 2015).
2/26; OR 0.43, 95% CI 0.04 to 5.02; N = 55; k = 1; I2 = not applicable;
Mousavi 2015). According to GRADE criteria, we judged the evidence 9.5.8 Suicide
to be of low certainty. There was no evidence of an effect for telephone contact on
suicides either by the post-intervention (0/25 versus 1/22; OR 0.28,
There was also no evidence of an effect for telephone contact on 95% CI 0.01 to 7.26; N = 47; k = 1; I2 = not applicable; Mousavi 2015),
repetition of SH by the 12-month assessment in a second trial 12-month (1/107 versus 1/109; OR 1.02, 95% CI 0.06 to 16.50; N =
(14/83 versus 15/89; OR 1.00, 95% CI 0.45 to 2.23; N = 172; k = 1; 216; k = 1; Cedereke 2002) or 24-month (1/293 versus 2/312; OR 0.52,
I2 = not applicable; Cedereke 2002), or by the 24-month follow-up 95% CI 0.05 to 5.89; N = 605; Vaiva 2006) follow-up assessments.
assessment in a third trial (44/293 versus 59/312; OR 0.76, 95% CI
0.49 to 1.16; N = 605; k = 1; I2 = not applicable; Vaiva 2006). Subgroup analyses
With respect to frequency of repetition of SH, there was no Whilst one trial stratified randomisation, this trial compared those
evidence of an effect for telephone contact by the post-intervention who engaged in three or fewer suicide attempts over the three
assessment in one trial (mean 0.04, SD 0.20, n = 25 versus mean years prior to trial entry to those who had engaged in four or more
0.18, SD 0.66, n = 22; MD -0.14, 95% CI -0.43 to 0.15; N = 47; k = 1; episodes over this time frame, rather than those engaging in a first
I2 = not applicable; Mousavi 2015). The mean number of episodes episode versus a repeat episode (Vaiva 2006). We were therefore
of SH was similar between arms in both Cedereke 2002 by the 12- unable to include these data in our review.
month assessment (0.31 versus 0.30) and in Vaiva 2006 by the 24-
month assessment (0.15 versus 0.19). However, as trial authors Sensitivity analyses
provided insufficient information to enable imputation of SDs, we Not applicable.
were unable to calculate the mean difference in the number of
repeat episodes of SH between arms in these two trials. Comparison 9.6: Telephone contact combined with emergency
cards and letters
Secondary outcomes
Two relatively large trials assessed the effectiveness of telephone
9.5.2 Treatment adherence contact combined with emergency cards and letters (for those
No data available. unable to be contacted via telephone) compared to TAU in adults
(weighted mean age: 38.4 ± 13.2 years; 64.5% female) presenting to
9.5.3 Depression the emergency department following a suicide attempt (Mouaffak
No data available. 2015, N = 302; Vaiva 2018, N = 987).
9.5.4 Hopelessness Primary outcome

No data available.
There was no evidence of an effect for telephone contact combined
with emergency cards and letters on repetition of SH by the
Whilst data on general functioning were available for one of these post-intervention assessment in one of these trials (22/152 versus
trials by the 12-month follow-up assessment (mean 61.4, SD 20.4 21/151; OR 1.05, 95% CI 0.55 to 2.00; N = 303; k = 1; I2 = not
versus mean 58.6, 20.2), it was unclear how many of the 163 applicable; Mouaffak 2015). According to GRADE criteria, we judged
participants with data on this outcome had been allocated to the the evidence to be of moderate certainty.
intervention and control arms (Cedereke 2002). We were therefore
unable to include these data in our review. The trial authors, For the second of these trials, information on SH repetition
however, reported that "[a]t 12 months there had been significant was combined with that for suicide deaths (Vaiva 2018). Despite
improvements within both the intervention and control groups in correspondence, we were unable to obtain disaggregated data for
global functioning (GAF)..." (Cedereke 2002, pg.87). these outcomes. We were therefore unable to include these data in
our analyses.
There was also no evidence of an effect for this intervention on
No data available. frequency of repeated SH by the post-intervention assessment in
one of these trials (mean 0.20, SD 0.58, n = 152 versus mean 0.23,
SD 0.84, n = 150; MD -0.03, 95% CI -0.19 to 0.13; N = 302; k = 1; I2 =
not applicable; Mouaffak 2015).

Informed decisions.
Although neither trial provided numeric data, both reported there As this latter trial used a cross-over design, we reported only data
was no effect for telephone contact combined with emergency from the post-intervention assessment (i.e. prior to cross-over) in
cards and letters on time to SH repetition: "[t]he intervention this review. Additionally, for one of these trials (i.e. Wei 2013),
had no significant impact on...the duration of the period that there were two intervention arms: CBT-based psychotherapy and
patients were free of attempts (Vaiva 2018, pg.5), and, there was no telephone-based psychotherapy. We therefore included here only
"significant differences between the two groups" (Mouaffak 2015, data for the telephone contact arm, and have split the comparator
pg.916). arm data following the advice in Higgins 2011.
Secondary outcomes Primary outcome

9.6.2 Treatment adherence 9.7.1 Repetition of SH
No data available. For one trial, correspondence with trial authors indicated there
were "no suicide attempts in both groups in those who did not drop
9.6.3 Depression out [at post-intervention]...We were unable to obtain information
No data available. from those who dropped out with respect to suicide attempts.
We did have one suicide attempt in the [intervention] group,
9.6.4 Hopelessness but this was before all interventions were completed and so
No data available. this was excluded from final analysis" (Sreedaran 2020, personal
communication).
For the remaining two trials, there was no evidence of an effect for
No data available. telephone-based psychotherapy on repetition of SH by the post-
intervention in two of these trials (OR 0.36, 95% CI 0.01 to 8.94;
participants = 185; studies = 2; I2 = 0%; Analysis 7.1). According to
No data available. GRADE criteria, we judged the evidence to be of low certainty.
9.6.7 Suicidal ideation There was also no evidence of an effect for telephone-based
No data available. psychotherapy on repetition of SH by the six-month (1/41 versus
9.6.8 Suicide Wei 2013), or 12-month follow-up assessments in one of these trials
There was no evidence of an effect for telephone contact combined
applicable; Wei 2013).
with emergency cards and letters by the post-intervention
assessment in one trial (1/152 versus 0/150; OR 2.98, 95% CI 0.12 to Secondary outcomes
73.74; N = 302; k = 1; I2 = not applicable; Mouaffak 2015), or by the
13-month follow-up assessment in the second trial (3/493 versus 9.7.2 Treatment adherence
8/494; OR 0.37, 95% CI 0.10 to 1.41; N = 987; k = 1; I2 = not applicable; There was no effect for mobile telephone-based psychotherapy on
Vaiva 2018). the proportion of participants who completed treatment by the
post-intervention assessment in one of these trials (8/13 versus
Subgroup analyses 7/12; OR 1.14, 95% CI 0.23 to 5.67; N = 25; k = 1; I2 = not applicable;
Randomisation was stratified by history of SH prior to trial entry in Sreedaran 2020).
one of these trials (Mouaffak 2015); however, there was no evidence
9.7.3 Depression
of an effect for telephone contact combined with emergency cards
and letters on repetition of SH by the post-intervention assessment There was also no evidence of an effect for mobile telephone-based
either in those with a history of SH (18/79 versus 17/72; OR 0.95, psychotherapy on depression scores by the post-intervention
95% CI 0.45 to 2.03; N = 151; k = 1; I2 = not applicable) or in those assessment in two of these trials (Analysis 7.2), or by the six-month
without this history at trial entry (4/77 versus 4/74; OR 0.96, 95% CI (mean 6.01, SD 8.87, n = 41 versus mean 5.85, SD 8.16, n = 40; MD
0.23 to 3.98; N = 151; k = 1; I2 = not applicable). 0.16, 95% CI -3.55 to 3.87; N = 81; k = 1; I2 = not applicable) or 12-
month (mean 5.73, SD 8.71, n = 36 versus mean 5.84, SD 8.23, n =
Sensitivity analyses 27; MD -0.11, 95% CI -4.32 to 4.10; N = 63; k = 1; I2 = not applicable)
Not applicable. follow-up assessments in one of these trials (Wei 2013).
Comparison 9.7: Telephone-based psychotherapy 9.7.4 Hopelessness
Three trials from developing countries (i.e. China, India, and Sri No data available.
Lanka) assessed the effectiveness of psychotherapy, incorporating 9.7.5 General functioning
principles from CBT-based psychotherapy, third-wave techniques,
and social support delivered by telephone over either a one-month No data available.
(Sreedaran 2020, N = 28), three-month (Wei 2013, N = 157), or six-
month (Marasinghe 2012, N = 68) period in adults (weighted mean
age: 32.6 ± 14.0; 69.6% female) presenting to services following an No data available.
episode of SH.

Informed decisions.
9.7.7 Suicidal ideation MISS Study (Fleischmann 2008, N = 1699). In one further trial,
There was evidence of an effect for mobile telephone-based participants nominated a support person in addition to receiving
psychotherapy for suicidal ideation scores at the post-intervention information and support using the original SUPRE-MISS model
assessment in one trial (mean 3.60, SD 1.60, n = 34 versus mean 7.30, (Naidoo 2014, N = 688).
SD 5.50, n = 34; MD -3.70, 95% CI -5.63 to -1.77; N = 68; k = 1; I2 = not Primary outcome
applicable; Marasinghe 2012).
One trial reported information on the proportion of participants
There was no evidence of an effect for information and support on
reporting suicidal ideation (Wei 2013); however, there was no
repetition of SH by the 18-month post-intervention assessment in
evidence of an effect for telephone-based psychotherapy on
two trials (OR 1.09, 95% CI 0.79 to 1.50; participants = 1853; studies =
the proportion reporting suicidal ideation at either the post-
intervention (37/80 versus 32/77; OR 1.21, 95% CI 0.64 to 2.27; N 2; I2 = 0%; Analysis 8.1). Whilst a third trial also reported information
= 157; k = 1; I2 = not applicable), six-month (26/80 versus 24/77; on repetition of SH by the post-intervention assessment, there were
OR 1.06, 95% CI 0.54 to 2.08; N = 157; k = 1; I2 = not applicable), major discrepancies for this outcome that we were unable to clarify
or 12-month (24/80 versus 25/77; OR 0.89, 95% CI 0.45 to 1.75; N = with trial authors (Naidoo 2014). According to GRADE criteria, we
157; k = 1; I2 = not applicable) follow-up assessments in this trial. judged the evidence to be of very low certainty.
However, it is notable that, for this trial, results were reported on As randomisation was conducted locally for each country included
the basis of those randomised despite the fact that a self-reported in the SUPRE-MISS study, we were also able to include results
measure was used, and high levels of dropouts were observed by for each of the five countries separately. Although there was no
the 12-month follow-up assessment. As we were unable to confirm difference between groups for the individual sites in Campinas,
these numbers with trial authors, results much be interpreted with Brazil (21/71 versus 10/64; OR 2.27, 95% CI 0.97 to 5.28; N = 135; k =
caution. 1; I2 = not applicable), Colombo, Sri Lanka (3/130 versus 5/121; OR
9.7.8 Suicide 0.55, 95% CI 0.13 to 2.34; N = 251; k = 1; I2 = not applicable), Karaj,
Iran (33/303 versus 28/298; OR 1.18, 95% CI 0.69 to 2.00; N = 601; k
Data obtained by correspondence indicated that there was no = 1; I2 = not applicable), and Yuncheng, China (1/58 versus 0/38; OR
evidence of an effect for telephone-based psychotherapy on suicide 2.01, 95% CI 0.08 to 50.60; N = 96; k = 1; I2 = not applicable), fewer
by the post-intervention assessment (Analysis 7.3). participants in the intervention group had repeated SH by the 18-
month period at the Chennai, India site (8/301 versus 17/260; OR
Subgroup analyses 0.39, 95% CI 0.17 to 0.92; N = 561; k = 1; I2 = not applicable).
Telephone-based psychotherapy was associated with an effect for
depression scores at the post-intervention assessment in males One secondary publication for the SUPRE-MISS study also reported
(mean 5.90, SD 2.40, n = 17 versus mean 13.30, SD 6.10, n = 17; MD data on frequency of SH for one site (i.e. Karaj, Iran) by the six-
-7.40, 95% CI -10.52 to -4.28; N = 34; k = 1; I2 = not applicable), but not month follow-up assessment (Hassanzadeh 2010). At this site, there
in females (mean 8.10, SD 6.30, n = 17 versus mean 11.60, SD 6.50, n was evidence of a increase in frequency of SH repetition in the
= 17; MD -3.50, 95% CI -7.80 to 0.80; N = 34; k = 1; I2 = not applicable) intervention and support arm relative to the TAU arm (mean 1.63,
in one trial (Marasinghe 2012). SD 1.19, n = 319 versus mean 1.17, SD 0.38, n = 310; MD 0.46, 95% CI
0.32 to 0.60; N = 629; k = 1; I2 = not applicable).
However, for suicidal ideation scores, whilst there was no evidence
of an effect for telephone-based psychotherapy at the post- Secondary outcomes
intervention assessment in males in this trial (mean 3.50, SD 1.80, 10.2 Treatment adherence
n = 17 versus mean 6.20, SD 5.50, n = 17; MD -2.70, 95% CI -5.45 to
0.05; N = 34; k = 1; I2 = not applicable), there was, however, an effect No data available.
for females (mean 3.80, SD 1.40, n = 17 versus mean 8.90, SD 6.20, n 10.3 Depression
= 17; MD -5.10, 95% CI -8.12 to -2.08; N = 34; k = 1; I2 = not applicable)
(Marasinghe 2012). Correspondence with trial authors revealed that information on
depression was recorded at one site only: Yuncheng, China (Xu
Sensitivity analyses 2012). There was evidence of an effect for information and
support on depression scores at this site by the post-intervention
One analysis within this comparison was associated with
assessment (mean 0.64, SD 0.29, n = 57 versus mean 0.52, SD 0.30, n
substantial levels of heterogeneity (Analysis 7.2, I2 = 90%); however,
= 54; MD 0.12, 95% CI 0.01 to 0.23; N = 111; k = 1; I2 = not applicable).
analyses did not indicate any individual study was associated with
excessive influence for this outcome. 10.4 Hopelessness
Comparison 10: Provision of information and support versus No data available.

TAU or another comparator
Two multicentre and multi-country studies investigated the
effectiveness of providing a one-off hospital-based information No data available.
session combined with regular home visits and/or telephone 10.6 Social functioning
contact in addition to TAU over an 18-month period in adults
(weighted mean age: 26.7 years, SD not reported; 62.6% female) No data available.
presenting to the emergency department following an episode of
SH: the START Study (Amadéo 2015, N = 190) and the SUPRE-
Informed decisions.
10.7 Suicidal ideation this group (7/14 versus 9/17; OR 0.89, 95% CI 0.22 to 3.66; N = 31; k
No data available. = 1; I2 = not applicable; Amadéo 2015).
10.8 Suicide Sensitivity analyses
There was evidence of an effect for information and support on Not applicable.
suicide deaths by the 18-month post-intervention assessment (OR
Comparison 11: Other multimodal interventions versus TAU or
0.12, 95% CI 0.03 to 0.44; N = 1889; k = 2; I2 = 0%; Analysis 8.2).
another comparator
For the SUPRE-MISS study, data on suicide deaths were also Three Zelen RCTs investigated the effectiveness of a package of
available for three sites in related publications (i.e. Chennai, India interventions, including CBT-based psychotherapy, remote contact
[Vijayakumar 2011], Karaj, Iran [Hassanzadeh 2010], and Yuncheng, interventions (e.g. telephone contact, letters, and/or postcards),
China [Xu 2012]). There was evidence of an effect for information and GP vouchers in adults (weighted mean age: 35.5 ± 12.5; 54.7%
and support on suicide deaths by the 18-month assessment at the female) admitted to emergency departments following an episode
Chennai, India site (1/302 versus 9/320; OR 0.11, 95% CI 0.01 to of SH (Gysin-Maillart 2016, N = 120; Hatcher 2015, N = 1474; Hatcher
0.91; N = 622; k = 1; I2 = not applicable), but not at the Karaj, Iran 2016, N = 365). For one of these trials, the treatment package was
(2/319 versus 2/310; OR 0.97, 95% CI 0.14 to 6.94; N = 629; k = culturally adapted for those who identified as of Māori ethnicity
1; I2 = not applicable), or the Yuncheng, China (0/57 versus 2/54; (Hatcher 2016).
OR 0.18, 95% CI 0.01 to 3.89; N = 111; k = 1; I2 = not applicable)
sites. Notably, the number of completed suicides in the intervention Primary outcome
group reported for these three subsamples was greater than the
number reported for the overall SUPRE-MISS cohort in the primary
trial (i.e. Fleischmann 2008). We were unable to confirm the correct There was no evidence of an effect for this package of interventions
number of completed suicides in the intervention group with the at post-intervention in terms of repetition of SH (Analysis 9.1).
authors. Including the one additional suicide for the intervention Using data for the consenting sample (i.e. including only those
group identified from the three subsample publications with the participants who, following treatment allocation, subsequently
data reported in the primary study reference, however, did not consented to participation), rather than all those randomised, for
materially affect the result obtained for the overall SUPRE-MISS Hatcher 2015 and Hatcher 2016, did not materially affect these
cohort. results. According to GRADE criteria, we judged the evidence to be
of very low certainty.
Subgroup analyses
One trial reported data on frequency of SH at post-intervention.
For the SUPRE-MISS study, data on repetition of SH were also
There was evidence of an effect for a multimodel package of
available for males and females separately (Fleischmann 2008).
interventions on frequency of SH in this trial (mean 0.08, SD 0.28,
Overall, across all five sites in this trial, there was no evidence of an
n = 60 versus mean 0.82, SD 1.89, n = 50; MD -0.74, 95% CI -1.27 to
effect on repetition of SH by the post-intervention assessment in
-0.21; N = 110; k = 1; I2 = not applicable; Gysin-Maillart 2016).
either males (30/349 versus 27/340; OR 1.09, 95% CI 0.63 to 1.88; N =
689; k = 1; I2 = not applicable) or females (36/514 versus 33/460; OR With regard to time to SH repetition, there was no evidence of a
0.97, 95% CI 0.60 to 1.59; N = 974; k = 1; I2 = not applicable). Breaking significant treatment effect for this package of interventions in two
these results down by sex for the individual sites involved in the trials (Analysis 9.2). Information on time to first SH presentation
SUPRE-MISS study revealed no effect for information and support was also reported in Hatcher 2015; however, "...there was no
on repetition of SH by the 18-month assessment for either sex at significant difference between the two groups in time to first re-
any of the five study sites: Campinas, Brazil (males: 4/21 versus presentation (log-rank test P = 0.6564)" (Hatcher 2015, pg.232).
3/25; OR 1.73, 95% CI 0.34 to 8.76; N = 46; k = 1; I2 = not applicable; As hazard ratios (HRs) and their accompanying 95% CIs were not
females: 17/50 versus 7/39; OR 2.35, 95% CI 0.86 to 6.44; N = 89; k reported in this trial, we were unable to include this result in our
= 1; I2 = not applicable), Chennai, India (males: 5/148 versus 7/125; review.
OR 0.59, 95% CI 0.18 to 1.91; N = 273; ; k = 1; I2 = not applicable;
females: 3/153 versus 10/153; OR 0.29, 95% CI 0.08 to 1.06; N = 306; Secondary outcomes
k = 1; I2 = not applicable), Colombo, Sri Lanka (males: 1/54 versus
females: 2/76 versus 2/68; OR 0.89, 95% CI 0.12 to 6.51; N = 144; k = No data available.
1; I2 = not applicable), Karaj, Iran (males 19/109 versus 14/118; OR
1.57, 95% CI 0.74 to 3.31; N = 227; k = 1; I2 = not applicable; females: 11.3 Depression
14/194 versus 14/180; OR 0.92, 95% CI 0.43 to 1.99; N = 374; k = 1; There was no effect for this package of interventions on depression
I2 = not applicable), Yuncheng, China (males: 1/17 versus 0/19; OR scores at the post-intervention assessment (Analysis 9.3).
3.55, 95% CI 0.14 to 93.01; N = 36; k = 1; I2 = not applicable; females
0/41 versus 0/38; OR not estimable, 95% CI not estimable; N = 79; k 11.4 Hopelessness
= 1; I2 = not applicable). There was also no apparent effect for this package of interventions
on hopelessness scores at the post-intervention assessment
For the START study, data on repetition of SH were reported
(Analysis 9.4).
separately for those with a history of SH prior to trial entry;
however, there was no evidence of an effect for information and However, the trial authors for one of these trials noted that
support on repetition of SH by the post-intervention assessment in "whilst there was a greater change in hopelessness scores at...12

Informed decisions.
months [i.e. the post-intervention assessment] in the intervention patient treatment (Van der Sande 1997), general hospital admission
group, the control group had a significantly lower baseline score (Waterhouse 1990), intensive outpatient treatment (Allard 1992;
[;]...because of the significant differences in baseline scores and Welu 1977), home-based psychotherapy and telephone contact
missing follow up data we...used a mixed linear model to estimate (Hawton 1981), and long-term therapy (Torhorst 1988).
the differences in scores at [the post-intervention assessment]".
Using this model, the trial authors found "there was a decrease Comparison 12.1: Continuity of care by the same therapist
in [h]opelessness scores in the treatment group compared to the One trial investigated the effectiveness of continuing aftercare
usual care group but this was statistically non-significant" (Hatcher with the same therapist (defined as continued therapeutic contact
2016, pg.889). with the original hospital therapist in an outpatient setting) versus
changing to a different therapist (defined as receiving therapy in
a specialised suicide prevention centre which involved changing
No data available. both therapist and institution) over a 12-month follow-up period
in adults (mean ± SD age not reported; 69.5% female) admitted to
11.6 Social functioning
hospital following an episode of self-poisoning (Torhorst 1987, N =
No data available. 141).
11.7 Suicidal ideation Primary outcome

One trial reported information on suicidal ideation scores (Gysin- 12.1.1 Repetition of SH
Maillart 2016); however, there was no evidence of an effect for this
There was no evidence of an effect for this intervention on
package of interventions on suicidal ideation scores by the post-
repetition of SH by the 12-month follow-up assessment in this trial
intervention assessment in this trial (mean 4.80, SD 7.88, n = 35
versus mean 4.62, SD 6.48, n = 34; MD 0.18, 95% CI -3.22 to 3.58; N
applicable; Torhorst 1987).
= 69; k = 1; I2 = not applicable).
Secondary outcomes
11.8 Suicide
There was no effect for this intervention package on suicides by the
post-intervention assessment in any trial (Analysis 9.5). For one of There was evidence of an effect for this intervention on the
these trials (i.e. Hatcher 2015), one death in the intervention arm proportion of participants who completed treatment compared to
and one in the control arm were due to uncertain causes and had alternative psychotherapy (49/68 versus 36/73; OR 2.65, 95% CI 1.32
yet to be investigated by the Coroner. However, assuming these to 5.34; N = 141; k = 1; I2 = not applicable; Torhorst 1987).
deaths to be attributable to suicide did not materially affect this
result. 12.1.3 Depression
Depression scores did not differ between groups at the 12-month

Subgroup analyses follow-up assessment in this trial (mean 6.20, SD 6.90, n = 65 versus
Randomisation was stratified by history of SH ( i.e. first SH episode mean 7.60, SD 9.20, n = 62; MD -1.40, 95% CI -4.24 to 1.44; N = 127;
versus repeat SH episode) in two of these trials (Hatcher 2015; k = 1; I2 = not applicable; Torhorst 1987).
Hatcher 2016); however, there was no difference in repetition of SH
12.1.4 Hopelessness
at post-intervention in either trial for either those without a history
of multiple episodes of SH prior to the index episode (i.e. first SH No data available.
episode) or for those with a history of multiple episodes of SH
(i.e. repeat SH episode) (Analysis 9.1). 12.1.5 General functioning
No data available.
As all trials included in this comparison used Zelen's design, we 12.1.6 Social functioning
were unable to undertake sensitivity analyses to investigate the No data available.
impact use of this design may have had on the results observed.
Two analyses within this comparison were associated with
No data available.
substantial levels of heterogeneity (Analysis 9.1.1, I2 = 81%; Analysis
9.2, I2 = 89%); however, analyses did not indicate any individual 12.1.8 Suicide
study was associated with excessive influence for any of these
outcomes. There was no evidence of an effect for this intervention on the
number of participants who died by suicide by the 12-month follow-
Comparison 12: Other mixed interventions versus TAU or up period (2/70 versus 3/66; OR 0.62, 95% CI 0.10 to 3.82; N = 136; k
another comparator = 1; I2 = not applicable; Torhorst 1987).
A number of single trials investigated the effectiveness of other Subgroup analyses
mixed types of interventions compared with TAU or another
comparator, including: continuity of care by the same therapist No included trial stratified randomisation by sex or repeater status.
(Torhorst 1987), interpersonal problem-solving therapy (McLeavey
1994), behaviour therapy (Liberman 1981), intensive in- and out-

Informed decisions.
Sensitivity analyses Comparison 12.3: Behaviour therapy

Not applicable. One small trial compared the effectiveness of behaviour therapy
versus alternative psychotherapy (i.e. insight-oriented therapy) in
Comparison 12.2: Interpersonal problem-solving therapy adults (mean age: 29.7 ± 8.8 years; 66.6% female) referred for
One small trial compared the effectiveness of interpersonal inpatient treatment following a suicide attempt (Liberman 1981, N
problem-solving skills training (IPSST) with alternative = 24).
psychotherapy (i.e. brief problem-oriented therapy) in adults
Primary outcome
(mean age: 23.9 ± 7.2 years; 74.3% female) admitted to accident
and emergency facilities following an episode of self-poisoning 12.3.1 Repetition of SH
(McLeavey 1994, N = 39). There was no evidence of an effect with regards to the proportion of
Primary outcome participants repeating SH by the 24-month follow-up period (2/12
versus 3/12; OR 0.60, 95% CI 0.08 to 4.45; N = 24; k = 1; I2 = not
12.2.1 Repetition of SH applicable).
There was no evidence of an effect for repetition of SH, defined as a
Secondary outcomes
'self-poisoning act', by the 12-month follow-up period (2/17 versus
4/16; OR 0.40, 95% CI 0.06 to 2.57; N = 33; k = 1; I2 = not applicable) 12.3.2 Treatment adherence
in this trial. No data available.
Secondary outcomes 12.3.3 Depression
Depression was measured using both the BDI and ZSRDS in
There was no evidence of an effect on the proportion of participants one trial. There was evidence of an effect for behaviour therapy at
who completed the full course of treatment in this trial (2/19 versus the post-intervention assessment according to both measures (BDI:
3/20; OR = 0.67, 95% CI 0.10 to 4.51; N = 39; k = 1; I2 = not applicable). mean 4.00, SD 4.00, n = 12 versus mean 14.00, SD 12.00, n = 12;
MD -10.00, 95% CI -17.16 to -2.84; N = 24; k = 1; I2 = not applicable;
There was, however, evidence of an effect for interpersonal ZSRDS: mean 32.00, SD 8.00, n = 12 versus mean 43.00, SD 14.00,
problem-solving therapy in terms of the number of treatment n = 12; MD -11.00, 95% CI -20.12 to -1.88; N = 24; k = 1; I2 = not
sessions attended (mean 5.30, SD 0.48, n = 17 versus mean 4.20, applicable).
SD 1.32, n = 16; MD 1.10, 95% CI 0.41 to 1.79; N = 33; k = 1; I2 = not
applicable). By the six-month follow-up assessment, although there was no
effect for behaviour therapy on depression according to the ZSRDS
12.2.3 Depression (mean 34.00, SD 8.00, n = 12 versus mean 41.00, SD 13.00, n = 12; MD
No data available. -7.00, 95% CI -15.64 to 1.64; N = 24; k = 1; I2 = not applicable), BDI
scores did show an effect (mean 4.00, SD 6.00, n = 12 versus mean
12.2.4 Hopelessness 13.00, SD 11.00, n = 12; MD -9.00, 95% CI -16.09 to -1.91; N = 24; k =
1; I2 = not applicable).
There was no evidence of an effect for hopelessness by the six-
month follow-up assessment in this trial (mean 6.12, SD 4.61, n = 19 12.3.4 Hopelessness
versus mean 4.35, SD 4.39, n = 20; MD 1.77, 95% CI -1.06 to 4.60; N
= 39; k = 1; I2 = not applicable). No data available.
12.2.5 General functioning 12.3.5 General functioning
No data available. No data available.
12.2.6 Social functioning 12.3.6 Social functioning
No data available. No data available.
12.2.7 Suicidal ideation 12.3.7 Suicidal ideation
No data available. There was no evidence of an effect for behaviour therapy on the
proportion of participants reporting suicidal ideation by the 24-
12.2.8 Suicide month follow-up assessment (5/12 versus 9/12; OR 0.24, 95% CI 0.04
to 1.36; N = 24; k = 1; I2 = not applicable).
There were no suicide deaths in either the intervention or
comparator arm by the 12-month follow-up period. 12.3.8 Suicide
Subgroup analyses No data available.

No included trial stratified randomisation by sex or repeater status. Subgroup analyses
Sensitivity analyses No included trial stratified randomisation by sex or repeater status.
Not applicable.

Informed decisions.
Sensitivity analyses Subgroup analyses

Not applicable. Whilst randomisation was stratified, data disaggregated by sex
were not reported.
Comparison 12.4: Intensive in- and outpatient treatment
One trial compared the effectiveness of brief psychiatric inpatient
admission followed by regular outpatient appointments and 24- Not applicable.
hour access to the psychiatric unit with TAU over a 12-month follow-
up period in adults (mean age: 36.3 ± 15.1 years; 57.7% female) Comparison 12.5: General hospital admission
admitted to a general hospital following a suicide attempt (Van der One trial investigated the effectiveness of admission to a general
Sande 1997, N = 274). hospital versus non-admission over a four-month follow-up period
in adults (mean age: 30.0 years, SD not reported; 62.3% female)
Primary outcome
presenting to an emergency room following an episode of self-
12.4.1 Repetition of SH poisoning and who had no immediate medical or psychiatric
There was no evidence of an effect for intensive in- and outpatient treatment needs (Waterhouse 1990, N = 77). In this trial, admission
treatment on repetition of SH by the 12-month follow-up period was described as consisting of little more than admission to an
(24/140 versus 20/134; OR 1.18, 95% CI 0.62 to 2.25; N = 274; k = 1; inpatient bed. The trial authors did not attempt to influence referral
I2 = not applicable). to psychiatric or other treatment services. The median length of
admission for those allocated to the experimental group was 17
There was no evidence of an effect for intensive in- and outpatient hours.
treatment on frequency of repetition of SH (mean 0.23, SD 0.57, n
= 140 versus mean 0.23, SD 0.81, n = 134; MD 0.00, 95% CI -0.17 to Primary outcome
0.17, N = 274; k = 1; I2 = not applicable). 12.5.1 Repetition of SH
There was also no evidence of an effect for intensive in- and There was no evidence of an effect for hospital admission on
outpatient treatment on time to SH repetition in this trial (HR 1.24, repetition of SH at the post-intervention assessment (2/38 versus
95% CI 0.68 to 2.27; N = 274; k = 1; I2 = not applicable). 2/39; OR 1.03, 95% CI 0.14 to 7.69; N = 77; k = 1; I2 = not applicable).
According to the GRADE criteria, we judged the evidence to be of
Secondary outcomes moderate certainty.
12.4.2 Treatment adherence There was also no evidence of an effect for general hospital
There was no effect for intensive in- and outpatient treatment in management on repetition of SH by the four-month follow-up
the total number of treatment sessions attended (mean 14.30, SD assessment (3/38 versus 4/39; OR 0.75, 95%CI 0.16 to 3.60; N = 77; k
24.20, n = 140 versus mean 11.40, SD 27.70, n = 134; MD 2.90, 95% CI = 1; I2 = not applicable) in this trial.
-3.27 to 9.07; N = 274; k = 1; I2 = not applicable).
Secondary outcomes
12.4.3 Depression 12.5.2 Treatment adherence
There was also no effect for intensive in- and outpatient treatment No data available.
on depression scores by the 12-month follow-up assessment (mean
30.80, SD 15.90, n = 94 versus mean 35.80, SD 16.20, n = 50; MD -5.00, 12.5.3 Depression
95% CI -10.52 to 0.52; N = 144; k = 1; I2 = not applicable).
No data available.
12.4.4 Hopelessness
12.5.4 Hopelessness
There was no effect for intensive in- and outpatient treatment on
The authors reported there was no difference in hopelessness
hopelessness scores by the 12-month follow-up assessment in this
scores at the post-intervention assessment (mean 10.29, SD 5.68
trial (mean 6.10, SD 5.00, n = 94 versus mean 7.50, SD 5.90, n = 50;
versus mean 10.21, SD 4.97); however, as they did not provide the
MD -1.40, 95% CI -3.32 to 0.52; N = 144; k = 1; I2 = not applicable).
numbers of patients in each group, we were unable to calculate the
12.4.5 General functioning MD and its associated 95% CI. No data on hopelessness scores by
the follow-up assessment were reported.
No data available.
No data available.
No data available.
There was no evidence of an effect for hospital admission on social
No data available. functioning by the four-month assessment in this trial (mean 0.41,
12.4.8 Suicide
SD 0.44, n = 16 versus mean 0.51, SD 0.40, n = 20; MD -0.10, 95% CI
-0.38 to 0.18; N = 36; k = 1; I2 = not applicable).
There was also no evidence of an effect for suicide by the 12-month
follow-up assessment in this trial (1/140 versus 2/134; OR 0.47, 95%
CI 0.04 to 5.30; N = 274; k = 1; I2 = not applicable).
Informed decisions.
12.5.7 Suicidal ideation 12.6.4 Hopelessness
There was no evidence of an effect for hospital admission on No data available.

suicidal ideation scores by the four-month follow-up assessment
(mean 0.22, SD 0.85, n = 27 versus mean 0.04, SD 0.20, n = 25; MD 12.6.5 General functioning
0.18, 95% CI -0.15 to 0.51; N = 52; k = 1; I2 = not applicable). For one of these trials, the authors found "[t]here was no
difference...in scores on the...GAS" (Allard 1992, pg.311) by the 24-
12.5.8 Suicide
month follow-up period. However, numerical data for this outcome
No data available. were not reported.
Subgroup analyses 12.6.6 Social functioning
No included trial stratified randomisation by sex or repeater status. No data available.
Sensitivity analyses 12.6.7 Suicidal ideation
Not applicable. No data available.
Comparison 12.6: Intensive outpatient treatment 12.6.8 Suicide
Two trials compared the effectiveness of intensive outreach One trial reported data on suicide deaths (Allard 1992). There was
interventions with standard outpatient care in adults (weighted no evidence of an effect for the intensive outpatient intervention
mean age: 29.0 years, SD not reported; 55.3% female) admitted to on suicides by the 24-month follow-up assessment in this trial (3/76
emergency departments following a suicide attempt (Allard 1992, versus 1/74; OR 3.00, 95% CI 0.30 to 29.52; N = 150; k = 1; I2 = not
N = 150; Welu 1977, N = 119). The first compared an intensive applicable).
intervention, involving psychiatrists and a social worker, a schedule
Subgroup analyses
of visits including at least one home visit, therapy provided where
needed, reminders (telephone or written), and home visits with No included trial stratified randomisation by sex or repeater status.
treatment by regular personnel in the same hospital over a 12-
month period (Allard 1992). In the second, a specialist, intensive Sensitivity analyses
outreach programme in which a community mental health team Not applicable.
contacted participants immediately after discharge and arranged
home visits and weekly or bi-weekly contact with therapists Comparison 12.7: Home-based psychotherapy and telephone
alongside routine psychiatric consultation was compared with TAU. contact
Primary outcome One trial investigated the effectiveness of problem-oriented

counselling delivered in two different ways, namely as a flexibly-
12.6.1 Repetition of SH timed home-based therapy, combined with open access via
There was no evidence of an effect for intensive outpatient telephone services to the general psychiatric service, versus
treatment on repetition of SH by either the four-month (3/62 versus treatment in weekly outpatient clinics, in adults (mean age: 25.2
9/57; OR 0.27, 95% CI 0.07 to 1.06; N = 119; k = 1; I2 = not applicable; ± 8.2 years; 69.8% female) referred to the psychiatric department
Welu 1977) or 24-month follow-up assessment (22/63 versus 19/63; of a general hospital following admission for self-poisoning
OR 1.24, 95% CI 0.59 to 2.62; N = 126; k = 1; I2 = not applicable; Allard (irrespective of suicidal intent) (Hawton 1981, N = 96).
1992).
Primary outcome
In the one trial that included information on frequency of repeated 12.7.1 Repetition of SH
SH by the 24-month follow-up assessment, the authors reported
that "the experimental subjects did not make fewer attempts than There was no evidence of an effect for home-based psychotherapy
the comparison subjects" (Allard 1992, pg.310). and telephone contact on repetition of SH by the 12-month follow-
up assessment in this trial (5/48 versus 7/48; OR 0.68, 95% CI 0.20
Secondary outcomes to 2.32; N = 96; k = 1; I2 = not applicable).
12.6.2 Treatment adherence Secondary outcomes
Data on treatment adherence were only available for one of 12.7.2 Treatment adherence
these trials (Allard 1992); however, as insufficient information was
reported to enable imputation of missing SDs in this trial, we were There was, however, evidence of an effect for home-based
unable to calculate the mean difference in the number of treatment psychotherapy and telephone contact on the proportion of
sessions attended. Nevertheless, the trial authors reported that participants who completed treatment over the course of the 12-
"[t]he mean numbers of encounters with psychiatrists were 12.35 month follow-up period (40/48 versus 20/48; OR 7.00, 95% CI 2.70
versus 1.54 (P < 0.001) in the first year and 2.11 versus 0.64 (P = to 18.13; N = 96; k = 1; I2 = not applicable).
0.071) in the second year" (Allard 1992, pg.311).
12.7.3 Depression
12.6.3 Depression Although this trial included data on depression, the trial authors
No data available. modified the scale used. We were therefore unable to include data
on this outcome in this review.

Informed decisions.
12.7.4 Hopelessness Overall, treatment adherence also appears to have been very low
No data available. in both groups as the "average number of sessions was 3.9 (out
of a possible 12 sessions) in the three-month group and 2.6 (out
12.7.5 General functioning of a possible 12 sessions) for the 12 month group" (Torhorst 1988,
pg.420). Again, however, it was unclear whether this difference was
No data available. statistically significant as insufficient information was reported to
12.7.6 Social functioning enable imputation of missing SDs in this trial.
Although this trial included data on social functioning, the trial 12.8.3 Depression
authors modified the scale used. We were therefore unable to Although numerical data on depression scores was not reported,
include data on this outcome in this review. means estimated by the review authors from a graph in the original
12.7.7 Suicidal ideation report suggested there was little difference in depression scores
between those allocated to long-term therapy and those allocated
Data obtained by correspondence suggested there was no effect for to short-term therapy by the 12-month follow-up assessment
suicidal ideation at either the post-treatment assessment (Mann- (estimated means 9.3 versus 6.7). However, insufficient information
Whitney U = 984, P = 0.29) or six-month follow-up assessment was reported to enable imputation of missing SDs for this outcome.
(Mann-Whitney U = 726, P = 0.14). As only median, rather than
mean, scores were available for this outcome, we were unable to The trial authors, however, stated that "self-evaluated
reproduce the mean difference in suicidal ideation scores between depressivity...improved considerably more for the patients of
the experimental and control groups in this review. the three-month program than for those of the 12-month
program" (Torhorst 1988, pg.421). This improvement was described
12.7.8 Suicide by the trial authors as statistically significant.
No data available.
12.8.4 Hopelessness
Subgroup analyses No data provided.
No included trial stratified randomisation by sex or repeater status. 12.8.5 General functioning
Sensitivity analyses No data provided.
Not applicable. 12.8.6 Social functioning
Comparison 12.8: Long-term therapy Whilst "[p]atients in the 3-month group evaluated themselves
according to the Social Adjustment Scale (SAS) significantly more
One trial investigated the effectiveness of long-term (one session
positively...than did the patients of the 12-month group" (Torhorst
per month over 12 months) versus short-term (one session per
1988, pg.421), numerical data for this outcome were not reported.
week over 12 weeks) outpatient psychotherapy on repetition of
SH over a 12-month follow-up period in adults (mean age: not 12.8.7 Suicidal ideation
reported, SD not reported; 100% female) admitted to hospital
following repeated episodes of self-poisoning (Torhorst 1988, N = No data provided.
80). The content of therapy was not specified. 12.8.8 Suicide
Primary outcome No data provided.
Subgroup analyses
There was no evidence of an effect for long-term therapy on
repetition of SH by the post-intervention assessment in this trial
(9/40 versus 9/40; OR 1.00, 95% CI 0.35 to 2.86; N = 80; k = 1; I2 = not Sensitivity analyses
applicable). According to GRADE criteria, we judged the evidence to
be of low certainty. Not applicable.
Secondary outcomes DISCUSSION

12.8.2 Treatment adherence This review included 76 trials, 21 (27.6%) of which have been
The trial authors did not provide numerical data on treatment completed since the previous version of this review (Hawton
adherence, although they stated, "[a]ttendance at the first session 2016). Previously, we commented that the promising results
was about equal for both groups (about 60%)" (Torhorst 1988, for CBT-based psychological therapy and DBT warranted further
pg.420). However, they further stated that "participation of the investigation of these approaches to understand which patients
12-month (long-term therapy) group dropped drastically by the benefit from these types of interventions. There were only a few,
second session to under 40%, while the participation of the patients generally small, trials of most other forms of psychosocial therapy,
in the 3-month (intensive short-term therapy) program remained providing little evidence of beneficial effects; however, these could
higher" (Torhorst 1988, pg.420). However, it was unclear whether not be ruled out.
this difference was statistically significant.

Informed decisions.
Summary of main results to obtain data on combined SH from the trial authors despite
correspondence. There was also no apparent effect for DBT group-
The trials included in this review investigated the effectiveness of based skills training only on any of the secondary outcomes
various forms of psychosocial interventions for SH in adults. investigated in this trial.
CBT-based psychotherapy DBT individual therapy
Individual-based CBT-based psychotherapy There is also probably little to no effect for DBT individual
Whilst 20 trials investigated the effectiveness of individual-based skills training only on absolute repetition or frequency of suicide
cognitive-behavioural therapy (CBT)-based psychotherapy, only reattempts or NSSI as compared to standard DBT, based on findings
four (20.0%) reported data on the primary outcome of this review of the single trial which included this comparison (Linehan 2015b).
(i.e., repetition of SH at post-intervention). Although there was Again, however, we were unable to obtain data on combined SH
imprecision in the effect estimate, on the basis of data from from the trial authors despite correspondence. There was also no
four of these trials, individual-based CBT-based psychotherapy apparent effect for DBT individual skills training only on any of the
may reduce repetition of SH as compared to TAU or another secondary outcomes investigated in this trial.
comparator by the end of the intervention. At longer follow-up
time points, there was more robust evidence of effect for this DBT prolonged-exposure protocol
intervention. However, there was no apparent effect for CBT-based On the basis of data from a single trial, there is probably little to no
psychotherapy on the frequency of SH, or time to SH repetition. effect of an experimental form of DBT in which participants were
given significantly longer cognitive exposure to stressful events
Few trials reported information on secondary outcomes. CBT- coupled with the standard DBT protocol on repetition of SH (Harned
based psychotherapy was associated with a relatively consistent 2014). There was also no apparent effect for the DBT prolonged
but small beneficial effect on depression, hopelessness, and exposure intervention on frequency of SH repetition, treatment
suicidal ideation scores as compared with TAU or another adherence, depression scores, or suicide.
comparator over time. There was no apparent effect for this
intervention on suicide, however. Mentalisation-based therapy (MBT)
Group-based CBT-based psychotherapy On the basis of data from a single trial, mentalisation-based
therapy (MBT) for adults referred to a specialist personality disorder
On the basis of data from a single trial in which CBT- treatment service reduces both absolute repetition of SH and
based psychotherapy was delivered in a group-based format, frequency of SH by the post-intervention assessment as compared
there is probably little to no effect of group-based CBT-based with TAU (Bateman 2009).
psychotherapy on repetition of SH as compared to TAU by the end
of the intervention. There was also no evidence of effect for this There was also an apparent effect for MBT on depression scores,
intervention approach at longer follow-up assessment points. general functioning scores, and social functioning scores by this
time point. However, there was no apparent effect for this
There was also no apparent effect of this intervention approach on intervention on treatment adherence. No participants died by
any of the secondary outcome measures assessed by this review. suicide in either trial arm by the post-intervention assessment.
Dialectical behaviour therapy (DBT) Emotion regulation psychotherapy
Standard DBT On the basis of data from two trials conducted by the same
On the basis of data from six trials, the evidence remains uncertain research group, emotion-regulation psychotherapy for women
as to whether standard DBT has any effect on absolute repetition diagnosed with borderline personality disorder provided in a
of SH by the post-intervention assessment compared to either group-based setting probably reduces absolute repetition of SH by
TAU or alternative psychotherapy in terms of the proportion of the post-intervention assessment (Gratz 2006; Gratz 2014). There
participants engaging in repeat SH by the post-intervention or was no apparent effect for this intervention on frequency of SH
12-month follow-up assessments. However, standard DBT may be repetition. However, correspondence with authors suggested that
associated with an effect for frequency of repeated SH by the post- this treatment did not require participants to abstain from SH.
intervention assessment. Instead, participants were encouraged to work on resisting urges to
engage in SH and, when SH occurred, to learn responses to it.
Whilst there was an apparent effect for standard DBT on depression
and suicidal ideation scores compared with TAU or another There was also evidence of an apparent effect for group-based
comparator at post-intervention, these effects were generally no emotion regulation psychotherapy on depression scores by the
longer apparent at longer follow-up time points; however, few trials post-intervention assessment. No participants died by suicide in
investigated these secondary outcomes. There was no apparent either trial arm by the post-intervention assessment.
effect for standard DBT on suicide.
Psychodynamic psychotherapy
DBT group-based skills training Whilst two trials investigated the effectiveness of psychodynamic
Based on one trial in which two variants of DBT were compared psychotherapeutic approaches as compared to TAU (Andreoli 2015;
to standard DBT, there is probably little to no effect of DBT Sahin 2018), we were only able to include data from the first of
group-based skills training on absolute or frequency of suicide these trials despite attempts to obtain data for the second trial by
reattempts or NSSI (Linehan 2015a). For this trial, we were unable correspondence. Therefore, based on data from one trial, there is
probably little to no effect of psychodynamic psychotherapy on
Informed decisions.
repetition of SH by the post-intervention assessment. However, Brief Collaborative Assessment and Management of Suicidality
there was an apparent effect of this intervention on time to SH (CAMS)-based intervention
repetition.
On the basis of data from a single trial, there is likely no effect of a
There was also evidence of an apparent effect for this intervention CAMS-based approach on repetition of SH by the 12-month follow-
on treatment adherence, depression scores, general functioning up assessment (O'Connor 2020). There was also no apparent effect
scores, and frequency of suicidal ideation episodes necessitating for this intervention on frequency of SH repetition by this time point
additional intensive psychiatric care by the post-intervention based on data estimated from graphics presented in the report of
assessment. There was no apparent effect on suicide deaths. this trial.
However, these results were all based on a single trial.
Limited data were available on any of the secondary outcomes
Case management assessed in this review. Although trial authors reported that
there were improvements in hopelessness and suicidal ideation
Five trials investigated the effectiveness of case management as scores by the six-month assessment in the original trial of this
compared to either TAU (Clarke 2002; Hvid 2011; Van Heeringen intervention (O'Connor 2015), this effect was no longer apparent
1995) or enhanced usual care (Kawanishi 2014; Morthorst 2012). On by the 12-month follow-up assessment in a subsequent trial of this
the basis of data from four of these trials, case management may intervention (O'Connor 2020).
have little to no effect on repetition of SH by the post-intervention
assessment. The impact of this intervention over longer term Brief guided Integrated Motivational-Volitional-focused
follow-up is uncertain as only one of these trials investigated intervention
outcomes beyond the post-intervention assessment time point.
On the basis of data from a single trial, there is likely no effect of the
There were inconsistent findings for case management on time to
Integrated Motivational-Volitional model either on the proportion
SH repetition in two trials.
of participants who engaged in a repeat episode of SH, the
Findings from a single trial indicated that case management may frequency of SH repetition, or in the proportion dying by suicide, as
be associated with an effect on the proportion of participants compared with TAU (O'Connor 2017).
who completed treatment, which was based on attendance
There was some evidence of an effect for this intervention on
for outpatient clinic appointments, the patient sample having
treatment adherence in this trial, however, there was also no
been identified before the trial as having failed to attend
indication that this approach led to a reduction in depression
such appointments (Van Heeringen 1995). However, few studies
scores in a second trial (Armitage 2016a). There was also no
reported data on other secondary outcomes. For one trial, although
evidence of an apparent effect for this intervention on suicide
data on hopelessness scores at post-intervention were collected,
deaths.
data on this outcome have not been reported in any secondary
publications of this trial to date (Kawanishi 2014), indicating that Brief self-guided Integrated Motivational-Volitional-focused
publication bias may have been present for this outcome. There intervention
was no apparent effect for case management on suicide.
The second intervention arm in Armitage 2016 investigated
Structured general practitioner (GP) follow-up the effectiveness of a self-guided version of the Integrated
Motivational-Volitional model as compared to TAU (i.e. Armitage
Based on results of a single trial of structured follow-up by the
2016b). However, in this trial, data on repetition of non-
participants' general practitioner (GP) compared with TAU in adults
fatal SH could not be disaggregated from data on suicidal
admitted to the acute ward of a general hospital following an
ideation, despite correspondence. Therefore, the evidence for
episode of self-poisoning (Grimholt 2015), this intervention may
these secondary outcomes is uncertain. There was no apparent
have little to no effect on repetition of SH by the post-intervention
effect for this intervention approach on depression scores by the
assessment.
post-intervention assessment, however.
There was also no apparent effect for structured GP follow-up on
Brief alcohol-focused intervention
treatment adherence, depression scores, hopelessness scores, and
suicidal ideation scores, although missing data for these secondary Based on a single trial of a brief intervention for alcohol misuse
outcomes was substantial (i.e. 70.5% to 91.3%). Therefore, the in SH patients, there is likely no effect of this intervention on
evidence for these secondary outcomes is uncertain. There was also repetition of SH by the six-month follow-up assessment (Crawford
no apparent effect for this intervention on suicide. 2010). However, only around half (47.1%) of those randomised
to the brief alcohol-focused intervention attended the treatment
Brief emergency department-based interventions session.
Five trials investigated one-off brief interventions delivered in
No suicide deaths were observed amongst the group of participants
the emergency department. Two were based, in a large part,
for whom information was available at the six-month follow-up.
on the Collaborative Assessment and Management of Suicidality
However, the trial authors warned that, as they were unable
(CAMS) approach (Jobes 2012), two were based on the Integrated
to track participants via their National Health Service (NHS)
Motivational-Volitional theoretical model of suicidal behaviour
identity numbers, they were unable to confirm numbers of suicides
(O'Connor 2011), and one focused on addressing alcohol misuse.
from national mortality data. Thus, there may have been suicide
deaths amongst those participants whom the authors were unable
to contact by the six-month follow-up assessment in this trial.
The original report did, however, identify a non-significant trend

Informed decisions.
towards reduced alcohol consumption per drinking day in those remains uncertain as to whether postcards have any effect
allocated to the intervention arm. on repetition of SH by the post-intervention assessment. The
single largest trial of this intervention, however, did find fewer
Remote contact interventions participants repeating SH in the experimental group (Hassanian-
A number of trials investigated the effectiveness of a variety Moghaddam 2011). This result is notable because the comparator
of remote contact interventions, including: emergency cards used in this trial would have consisted of little more than discharge
(Evans 1999a; Morgan 1993), coping cards (Wang 2016), general because of the paucity of psychiatric services in Iran as compared
practitioners' (GP) letters (Bennewith 2002), postcards (Beautrais to Australia, New Zealand, and the UK, where these trials were
2010; Carter 2005; Hassanian-Moghaddam 2011; Kapur 2013), conducted and which have well-developed services. This raises the
telephone contact (Cedereke 2002; Mousavi 2015; Vaiva 2006), possibility that this type of intervention may be more effective in
telephone contact combined with emergency cards and letters such settings. Additionally, the postcards used in this trial included
(Mouaffak 2015; Vaiva 2018), and telephone-based psychotherapy religious and philosophical messages in addition to providing
(Marasinghe 2012; Sreedaran 2020; Wei 2013). general support, which may also explain their apparent efficacy in
reducing SH and suicidal behaviour in this setting.
Emergency cards
There was no apparent effect of postcards on frequency of SH
On the basis of data from two trials, emergency cards may have repetition by this time point. It should be noted that the positive
little to no effect on repetition of SH by the post-intervention effect on frequency of repetition of SH as reported in one of these
assessment (Evans 1999a; Morgan 1993). In the original report for trials was, according to the trial's author, largely accounted for by
one of these trials, however, a post hoc subgroup analysis indicated difference in repetition in a small subsample (fewer than 3% of the
that receipt of the emergency card may be associated with an total sample) of women with a history of three or more episodes
increased risk of repetition of SH in those with a history of multiple of SH prior to trial entry (Carter 2005). There was also no apparent
episodes of SH prior to the index episode (Evans 1999a). effect of this intervention on suicide deaths.
There was also no apparent effect for this intervention on suicide Telephone contact
deaths on the basis of data reported in one of these trials (Evans
1999a). No data on other secondary outcomes were reported in On the basis of data from one trial at each time point, telephone
either of these two trials. contact may have little to no effect on repetition of SH by either
the post-intervention (Mousavi 2015), 12-month (Cedereke 2002),
Coping cards or 24-month (Vaiva 2006) follow-up assessments. There was also
no evidence of an effect for this intervention on frequency of SH
A single trial investigated the effectiveness of a coping card repetition. There was also no apparent effect for telephone contact
intervention, in which participants were encouraged to note down on suicide, or on any of the other secondary outcomes.
alternative activities they could engage in when feeling suicidal,
resources they found helpful when seeking help, as well as the Telephone contact combined with emergency cards and letters
numbers of a 24-hour crisis line and local medical services (Wang
2016). On the basis of data from this trial, there is probably little Two trials investigated the effect of combining telephone contact
to no effect of coping cards on repetition of SH by the post- with emergency cards and letters for those unable to be contacted
intervention assessment. There may be an apparent effect for this by telephone (Mouaffak 2015; Vaiva 2006). On the basis of data
intervention on time to SH repetition. from the first of these trials, telephone contact combined with
emergency cards and letters probably has little to no effect on
There was no apparent effect of coping cards on hopelessness repetition of SH by the post-intervention assessment. However,
scores at post-intervention. However, whilst the authors measured data from the second trial of this intervention approach was
depression and suicidal ideation scores at post-intervention, excluded as information on non-fatal SH repetition was combined
we were unable to obtain data on these outcomes despite with that for suicide deaths and we were unable to obtain
correspondence. Therefore, the evidence for these secondary disaggregated data from the trial authors in time for publication.
outcomes is uncertain. There was also no apparent effect for this intervention on frequency
of SH repetition, time to SH repetition, or on suicide. Neither
General practitioner (GP) letters trial investigated other secondary outcomes, including depression,
There is likely no effect of general practitioners (GP) letters sent general or social functioning, or suicidal ideation.
to participants following their discharge from hospital after SH on Telephone-based psychotherapy
repetition of SH by the six-month follow-up assessment in a single
cluster-RCT (Bennewith 2002). There was also no apparent effect Three trials investigated the effectiveness of psychotherapy
for this intervention on time to SH repetition. These results were delivered via telephone (Marasinghe 2012; Sreedaran 2020; Wei
based on a single cluster-RCT, which may have overestimated the 2013). In all three, the intervention approach incorporated
effectiveness of this intervention. No data on any of the secondary principles of CBT-based psychotherapy, third-wave techniques,
outcomes were reported, however. and social support. On the basis of data from two of these
trials, telephone-based psychotherapy may have little to no effect
Postcards on repetition of SH by the post-intervention assessment, or by
Four trials investigated the effectiveness of postcards sent on the six- or 12-month follow-up assessments based on results in
a regular basis over a 12-month period as compared to TAU one of these trials. There was no apparent effect for telephone-
(Beautrais 2010; Carter 2005; Hassanian-Moghaddam 2011; Kapur based psychotherapy on treatment adherence, depression, suicidal
2013). On the basis of data from these four trials, the evidence ideation, or suicide.

Informed decisions.
Provision of information and support assigned to the IPSST group did attend a greater number of
treatment sessions.
On the basis of data from two multicentre and multi-country
trials, one of the START model (Amadéo 2015) and a second of Behaviour therapy
the SUPRE-MISS model (Fleischmann 2008), in which participants
received a hospital-based information service combined with Based on a single trial, there is likely no effect of behaviour
regular home support, telephone support or both, the evidence therapy compared to alternative psychotherapy (i.e. insight-
remains uncertain as to whether this intervention has any effect oriented therapy) on repetition of SH by the 24-month follow-
on repetition of SH by the post-intervention assessment. We had up assessment, although there was an apparent effect for
to exclude one further trial of this approach from our analyses as behaviour therapy on depression scores as compared to alternative
there were major discrepancies in the data reported which we were psychotherapy, at least in the short term (i.e. post-intervention
unable to clarify with the trial authors despite correspondence assessment) (Liberman 1981). Behaviour therapy was also
(Naidoo 2014). associated with mixed findings with respect to suicidal ideation
scores in this trial.
There was an apparent effect for this intervention approach on
suicide deaths. However, we have noted that there is a discrepancy Intensive in- and outpatient treatment
between findings for the overall cohort for one of these trials Based on a single trial, there is likely no effect of brief
(i.e. Fleischmann 2008) and those reported for the individual inpatient psychiatric admission admission followed by regular
sites (i.e. Hassanzadeh 2010; Vijayakumar 2011; Xu 2012), in that outpatient appointments plus 24-hour access to a treatment
the number of suicides reported for the overall cohort for the service (i.e. intensive in- and outpatient treatment) compared to
intervention arm was fewer than that reported in the three local TAU on repetition of SH, frequency of SH repetition, or on time to SH
site reports (i.e. two versus three respectively). Data on secondary repetition by the 12-month follow-up assessment (Van der Sande
outcomes were only reported for the individual trial sites, rather 1997). There was also no apparent effect for this intervention on
than for the overall cohort for these trials. treatment adherence, depression scores, hopelessness scores, or
suicide.
Other multimodal interventions
Three Zelen RCTs investigated the effectiveness of a package of General hospital admission
interventions, including CBT-based psychotherapy, remote contact Based on a single trial involving patients who would normally have
interventions (e.g. telephone contact, letters, and/or postcards), been admitted to a general hospital following SH, there is probably
and GP vouchers in adults admitted to emergency departments little to no effect of general hospital admission compared with
following an episode of SH (Gysin-Maillart 2016; Hatcher 2015; discharge from the hospital on repetition of SH by either the post-
Hatcher 2016). For one of these trials, the treatment package intervention or the four-month follow-up assessment (Waterhouse
was culturally adapted for those who identified as being of Māori 1990). There was also no apparent effect for this intervention on
ethnicity (Hatcher 2016). The evidence remains uncertain as to social functioning or suicidal ideation scores by either time point.
whether this package of interventions has any effect on repetition However, as trial entry was limited to low-risk participants, only
of SH by the post-intervention assessment, or on time to SH around 15% of presenting patients were eligible for inclusion in this
repetition. There was an apparent effect on frequency of SH trial.
repetition in one of these trials (Gysin-Maillart 2016).
Intensive outpatient treatment
There was no evidence of an apparent effect for this package of
interventions on depression, hopelessness, or suicidal ideation Based on two trials that compared a combination of intensive
scores by the post-intervention assessment. There was also no therapies, including psychotherapy, behaviour therapy, and family
evidence of an apparent effect for this package of interventions on therapy versus standard outpatient care, there is likely no effect
suicide by the post-intervention assessment. of intensive outpatient treatment on repetition of SH by either
the four-month (Welu 1977) or 24-month (Allard 1992) follow-
Other mixed interventions up assessments. There is likely no effect of this intervention
on treatment adherence, general functioning, or suicide deaths;
Continuity of care by the same therapist
although secondary outcomes were only investigated in one of
Based on a single trial, there is likely no effect of continuity of care these two trials (Allard 1992).
by the same therapist compared to receiving therapeutic contact
from a different therapist on repetition of SH by the 12-month Home-based psychotherapy and telephone contact
assessment (Torhorst 1987). There was an apparent effect for this Based on a single trial, there is likely no effect of home-based
intervention on treatment adherence, but no such effect on either psychotherapy on repetition of SH by the 12-month follow-up
depression scores or suicide. assessment (Hawton 1981). Whilst there was an apparent effect
for this intervention on treatment adherence, there was no such
Interpersonal problem-solving therapy
effect on suicidal ideation scores. As modified scales were used to
Based on a single trial, there is likely no effect of interpersonal assess depression and social functioning, however, we were unable
problem-solving skills training (IPSST) compared to alternative to include data for these secondary outcomes in our review.
psychotherapy (i.e. brief problem-oriented psychotherapy) on
repetition of SH, hopelessness scores, and suicide by the 12-month Long-term therapy
follow-up assessment (McLeavey 1994). There was also no overall Based on a single trial, long-term therapy (the therapeutic
effect for this intervention on treatment adherence, although those content and focus of this approach was not specified) may have

Informed decisions.
little to no effect on repetition of SH by the post-intervention and support. For the START Study, although the trial was originally
assessment compared with short-term intensive therapy (Torhorst scheduled to be conducted in 13 countries (De Leo 2013), data from
1988). Overall treatment adherence was fairly low in both groups, only one of these sites (i.e. French Polynesia; Amadéo 2015) has
however. Estimates of scores from graphs also suggests there was been published to date. Additionally, while the SUPRE-MISS trial
no apparent effect for long-term therapy on depression scores. was scheduled to be conducted in 18 sites (Fleischmann 2002),
data from only five of these were reported in Fleischmann 2008
Overall completeness and applicability of evidence and a related publication (Bertolote 2010). Secondary data from
three sites (i.e. China [Xu 2012], Iran [Hassanzadeh 2010], and India
Completeness of evidence
[Vijayakumar 2011]) have also been published. However, data for
Where it was unclear whether a trial satisfied our inclusion criteria, the remaining sites involved in this trial have not been published to
we contacted corresponding trial authors for clarification. We date.
also contacted corresponding authors where data were either not
clearly reported, or where we required data reported in a different Presence of publication bias could only be formally evaluated for
format to allow for their inclusion in a meta-analysis. However, three meta-analyses for CBT-based psychotherapy with respect to
despite engaging in over 200 emails with corresponding authors repetition of SH at six months (Figure 4) and 12 months (Figure 5),
we were not always able to obtain all relevant data. This was due and for suicide deaths at final follow-up (Figure 6). In all cases, some
to a combination of non-response to our enquiries and to authors funnel plot asymmetry was apparent and seemed to affect the right
being unable to access relevant data, often due to moving on to side of the plot suggesting that there may be unpublished trials
later positions or as a result of working from home due to COVID-19 in which the intervention was found to be ineffective. However, as
pandemic quarantine orders. This is a common problem in meta- the remaining meta-analyses in this review included fewer than
analyses (Selph 2014). 10 trials, we were unable to investigate publication bias for these
analyses.
There are some concerns with regards to completeness of evidence
for two large multicentre and multi-country trials of information
Figure 4. Funnel plot: CBT-based psychotherapy on repetition of SH at six-months.
0 SE(log[OR])
0.5
1.5
OR
2
0.1 0.2 0.5 1 2 5 10

Informed decisions.
Figure 5. Funnel plot: CBT-based psychotherapy on repetition of SH at 12-months.
0 SE(log[OR])
0.5
1.5
OR
2
0.1 0.2 0.5 1 2 5 10

Informed decisions.
Figure 6. Funnel plot: CBT-based psychotherapy on suicide deaths by final follow-up.
0 SE(log[OR])
0.5
1.5
OR
2
0.01 0.1 1 10 100
Whilst all but two of the included trials reported information on good evidence that there are higher risks of self-harm in those who
repetition of SH, publication bias may have been more common for are gender diverse (Newcomb 2020).
the secondary outcomes assessed by this review. However, formal
testing of publication bias was not possible due to the small The majority of trials included either patients who have all engaged
number of trials. Therefore, we cannot rule out the possibility that in intentional drug overdoses or self-poisoning, or samples where
publication bias may have affected the results of the other analyses the majority had, again reflecting the typical pattern observed in
in this review. This is a problem that commonly affects clinical data patients who present to general hospitals following SH (Hawton
(Easterbrook 1991). 2007). However, there are other important patient subgroups,
such as those who engage in self-cutting, who may have different
Applicability of evidence treatment needs (Hawton 2004). None of the trials included in this
review specifically focused on these patients; although it should be
The majority of participants in these trials were female, reflecting
noted that method switching is common in those who engage in
the typical pattern in hospital-presenting populations (Hawton
repeat episodes of SH (Witt 2019). In some trials there was a lack
2008). Only four trials stratified randomisation by sex (Hvid 2011;
of information relating to the method of SH. Seventeen (22.4%)
McAuliffe 2014; Van der Sande 1997; Walton 2020) whilst data
trials focused on those with a history of repeated SH, which is a
were analysed separately by sex in six further trials (Bennewith
particular issue in this clinical population, given the association of
2002; Carter 2005; Fleischmann 2008; Hassanian-Moghaddam
individuals with a history of repeat episodes having a greater risk
2011; Kapur 2013; Marasinghe 2012). Trials where sex was reported
of suicide (Zahl 2004). However, only 14 investigated impacts of
largely indicated benefits for females, but not males, in line with a
psychosocial interventions for those with an initial episode of SH
previous review (Krysinska 2016). However, as these trials generally
versus those engaging in repeated SH (Amadéo 2015; Bennewith
included fewer males, it may be that subgroup results for males
2002; Carter 2005; Evans 1999a; Gratz 2014; Hatcher 2011; Hatcher
were underpowered. Given that there are some differences in the
2015; Hatcher 2016; Hassanian-Moghaddam 2011; Kapur 2013; Lin
motives for SH in males as compared to females (Claes 2007),
2020; McAuliffe 2014; Morthorst 2012; Mouaffak 2015). Outcomes
further work on the treatment needs and preferences of males who
were generally not stratified by recruitment setting (e.g. emergency
engage in SH, as well as their experiences of clinical services, and
department, community, and/or GP-based referrals). This could
how these may differ from females who engage in SH, is warranted.
be a focus of future trials and reviews. Secondary outcomes were
Further, a binary approach to gender was evident in the majority
also infrequently assessed which limits interpretation of possible
of trials. There was therefore poor attention to, and reporting
mechanisms of effect.
of, outcomes for those with a non-binary gender identity. There is

Informed decisions.
Compared to previous versions of this review (Hawton 2016), based on self-reported information with those obtained from
there is now greater representation of trials from low-to-middle- objective sources to investigate what impact, if any, this bias may
income countries, including: Iran (Hassanian-Moghaddam 2011; have had on the estimate of treatment effectiveness.
Mousavi 2015; Mousavi 2017), Taiwan (Lin 2020; Wang 2016), China
(Wei 2013), India (Sreedaran 2020), Malaysia (Armitage 2016), Additionally, participants and clinical personnel were, typically, not
Pakistan (Husain 2014), South Africa (Naidoo 2014), and Sri Lanka blind to allocation owing to likely differences in treatment intensity
(Marasinghe 2012). Additionally, two multicentre and multi-country between the intervention and control arms (Witt 2020a). Indeed,
trials were conducted in a number of countries, including several due to safety considerations, unblinding may be unavoidable in
low-to-middle-income countries (e.g. Brazil, China, India, and these types of trials. However, given that repetition of SH was based
Iran (Fleischmann 2008), and French Polynesia (Amadéo 2015)). on self-report in a number of the included trials (Amadéo 2015;
Armitage 2016; Brown 2005; Davidson 2014; Fleischmann 2008;
This review focused exclusively on those who engaged in SH. Gratz 2006; Gratz 2014; Harned 2014; Hassanian-Moghaddam 2011;
As a result, we have excluded trials in which participants Husain 2014; Liberman 1981; Linehan 1991; Linehan 2006; Linehan
were diagnosed with conditions such as borderline personality 2015; McMain 2009; Mousavi 2015; Mousavi 2017; Naidoo 2014;
disorder but where SH was not required for trial entry. We also O'Connor 2015; O'Connor 2020; Priebe 2012; Sahin 2018; Slee 2008;
excluded trials in which participants engaged in repetitive self- Tapolaa 2010; Torhorst 1987; Turner 2000; Walton 2020; Wei 2013;
injurious behaviour in the context of an intellectual disability Weinberg 2006), this may introduce potential bias.
or developmental disorder (e.g. an autism spectrum disorder).
Readers interested in the use of psychosocial interventions for Lastly, the trials included in this review were, in general, relatively
these patient groups are instead referred to the relevant reviews small to detect differences in proportions of patients who engage
(Cristea 2017; Oliver 2010). in a repeat episode of SH, although it is acknowledged that some
of the trials were feasibility studies (Davidson 2014; Evans 1999b;
Quality of the evidence Gibbons 1978; Harned 2014; Kapur 2013; O'Connor 2015; O'Connor
2020; Owens 2020; Sreedaran 2020). Whilst sample sizes have
Certainty of evidence, as assessed using the GRADE approach, was increased over time, most trials in this field are still underpowered.
generally moderate to very low suggesting that further research We have previously calculated that trials in this field may need to
is likely to have an important impact on our confidence in the recruit up to a minimum of 1862 participants per arm to detect an
estimates of treatment effectiveness, and may in fact change the effect for repetition of SH with 80% power at the conventional alpha
estimates. This is particularly likely to affect results for those level (Witt 2020a). Future trials should therefore supply a priori
interventions that so far have only been assessed in single trials. power calculations to justify their sample size.
Additionally, using the Cochrane 'Risk of bias' tool version 2.0
Potential biases in the review process
(Sterne 2019), for almost all (85.5%) trials included in this review
there were some concerns or a high risk of bias in relation to at We are confident that we have identified all relevant psychosocial
least one aspect of trial design, with weaknesses most commonly interventions for SH in adults. However, we cannot rule out the
observed with respect to selection of the reported result and possibility that some relevant outcome data may be missing from
measurement of the outcome. this review. Although data on repetition of SH were available for
all but two of the included trials, limited data were available on
For most trials, insufficient information was reported to determine secondary outcomes. Nevertheless, by using the random-effects
whether data were analysed in accordance with a prespecified plan. model in all analyses, our results possess greater generalisability
In 2015, the International Committee of Medical Journal Editors than if we had used the fixed-effect model (Erez 1996).
(ICMJE) recommended all clinical trials should be preregistered in
a public trials registry (Witt 2020a). Whilst around half (54.5%) of It is worth noting that the categorisation and grouping of
the 22 trials published subsequent to this recommendation were interventions in this review may, in some cases, obscure the nature
preregistered, in some cases there was insufficient detail provided of the discrete interventions within a particular comparison. For
within the clinical trial register to determine how key outcome(s) example, a decision was made to group brief problem solving
were defined. This made it difficult to determine whether there therapy (PST) with CBT into a single comparison we have referred
had been any substantive changes to the proposed analysis to as 'CBT-based psychotherapy'. As PST is usually a component of
plan and, if so, the reasons for any such departures. Future trials CBT, we have included trials where PST was the key therapeutic
should provide sufficient detail within the clinical trial register to modality. It is important that those making decisions about the
determine how key outcome(s) are defined and measured to aid in interventions examined in this review attend to the particular
the determination as to whether there has been any substantive therapeutic components used in each trial included in any
changes to the proposed analysis plan, and if so, the reasons for any particular comparison (as we have detailed in the Characteristics of
such departures. included studies table).
There were also some concerns relating to bias in the measurement Agreements and disagreements with other studies or
of the outcome. This was typically because repetition of SH was reviews
based on self-reported information. Given that around two-thirds
of SH recorded in medical and clinical records are not reported This review is an update of the 2016 Cochrane Review on
by participants, prevalence estimates derived from self-reported psychosocial interventions for SH in adults (Hawton 2016). The
information alone may underestimate the true rate of SH (Mitchell previous review included 55 trials of seven different approaches,
2016). By supplementing data on self-reported SH with information finding that CBT-based psychological therapy may result in fewer
from clinical or medical records, future trials could compare results individuals repeating SH whilst DBT may lead to a reduction in

Informed decisions.
frequency of repeated SH. This update concurs with its previous behavioural therapy (CBT)-based psychotherapy for individuals in
iteration. There appears to be a probable beneficial effect for CBT- reducing repetition of SH compared with treatment-as-usual (TAU),
based psychotherapy on repetition of SH as compared to TAU or particularly over the longer term. This is perhaps unsurprising as
another comparator immediately after the end of therapy, and this these trials were generally much briefer in terms of the number of
effect appears to be maintained over time. There also appears to therapy sessions delivered (e.g., often between 3 to 5 sessions, and
be limited positive findings for DBT in terms of reduced frequency never more than 10 sessions) as compared with traditional CBT-
of SH. based psychotherapy for depression. Services may wish, where this
is feasible, to ensure availability of clinicians to deliver these types
We identified 18 further reviews that included a focus on of intervention. This is in keeping with official guidance (Carter
psychosocial interventions for SH in adults that have been 2016; NICE 2011).
completed since the previous version of this review was published.
Six were systematic reviews (D'Anci 2019; Hanratty 2019; Inagaki There were also some positive effects, particularly with regards
2019; Krysinska 2017; Milner 2015; Tighe 2018), 10 included to frequency of SH repetition, for several interventions for the
meta-analysis (Bornheimer 2020; Briggs 2019; Calati 2016; DeCou treatment of individuals with borderline personality disorder (in
2019; Gøtzsche 2017; Hetrick 2016; Meerwijk 2016; Milner 2015; which repetitive self-harm is often a feature), noting that the
Padmanathan 2020; Riblet 2017), and two were narrative reviews trial participants were mostly female in these trials. Arguably,
(Ghanbari 2015; Pirkis 2020). The majority of these reviews included where patients engage in repeated episodes of SH, reduction
studies where participants had mixed clinical presentations in the frequency of SH could be viewed as a key outcome.
(i.e. clinically significant levels of suicidal ideation and/or SH), and Variation in the method of provision of DBT does not appear
not all were limited to RCTs. to differ in effectiveness from standard DBT. The standard DBT
approach is, however, lengthy (typically one year; Linehan 1991)
Of these reviews, those that have focused on specific intervention and necessitates considerable therapist time. We also found
approaches, including acceptance and commitment therapy some positive effects for both MBT and emotion-regulation
(ACT)-based approaches (Tighe 2018), brief contact interventions psychotherapy delivered in a group-based format in individuals
(Ghanbari 2015; Milner 2015; Milner 2016), CBT (Gøtzsche 2017), the diagnosed with borderline personality disorder, although these
Collaborative Assessment and Management of Suicidality (CAMS) findings were based on a single trial (MBT) or trials conducted by
model (Hanratty 2019), DBT (DeCou 2019), psychoanalytic and the same group (emotion-regulation psychotherapy). We therefore
psychodynamically-oriented therapy (Briggs 2019), and provision recommend further evaluation of these approaches. Given the
of information and support (Pirkis 2020), have generally reported multi-component nature of these intervention approaches for
evidence of benefit for the approach examined; although two treatment of individuals with borderline personality disorder,
reviews of brief contact interventions (Milner 2015; Milner 2016) greater use of head-to-head trials, which allow for dismantling
and one each of the ACT (Tighe 2018) and CAMS model (Hanratty of the effect size(s) between one or more component(s), should
2019) indicated there was limited evidence for these approaches on be considered, especially as this might help to identify effective
repetition of SH, in line with findings from our review. components which could be delivered more briefly.
Of these reviews that have adopted a broader focus, whilst they Remote contact interventions, such as sending regular postcards
generally indicated that delivering some form of psychotherapy to patients, have been evaluated in several trials. Whilst positive
is likely to be more effective than nothing (e.g. Bornheimer 2020; results compared to TAU with regard to repetition of SH at
Calati 2016; Hetrick 2016; Inagaki 2019; Meerwijk 2016; Riblet both short- and longer-term follow-up have been reported, the
2017), these reviews have tended to statistically pool results from main positive result comes from a single large trial conducted
very different interventions together and so the results are largely in a resource-poor setting (Iran) where mental health services
meaningless for clinical practice as they provide little insight into are sparse (e.g. Iran has an average of 2.0 psychiatrists and 9.5
which approach may be most beneficial for particular clinically mental health-trained nurses per 100,000 persons; WHO 2019).
relevant subgroups of patients. Therefore this relatively low intensity intervention may represent
a considerable improvement over the likelihood of receiving little
Future reviews should undertake network meta-analysis to
to no aftercare. Remote contact interventions may therefore hold
investigate which component(s) of these typically multi-
some promise in settings where there are very limited psychiatric
component intervention approaches are most effective. Individual
services, and should remain an area for further development in
participant data meta-analyses would also assist with the
such settings.
identification of clinically relevant subgroups of patients who may
benefit from certain more intensive forms of intervention. An argument for intervention following an episode of SH is that
it may improve other outcomes even if it does not reduce SH.
AUTHORS' CONCLUSIONS Secondary outcomes were examined variably in many of the
included trials. There was only limited evidence that experimental
Implications for practice interventions result in better outcomes in these other domains.
The number of trials and range of interventions identified in this CBT-based psychotherapy, DBT, MBT, and emotion-regulation
version of the review represents a considerable increase compared psychotherapy may lead to better outcomes in depression severity,
with the previous version (Hawton 2016). In this update, we hopelessness, and possibly also social functioning in the short
found 76 non-overlapping trials of a wide range of psychosocial term. Case management may improve treatment adherence.
interventions for adults who engage in SH. Overall, there were However, the certainty of evidence was very low to moderate.
significant methodological limitations across the trials included
in this review. There may be some positive effects for cognitive Indeed, few specific types of psychosocial interventions appear to
perform better than TAU. However, TAU was not well described
Informed decisions.
in most clinical trials we examined. TAU also varies greatly across matter to those who engage in SH is required to further inform
clinical settings (Witt 2018). For example, in one trial in which the intervention development (Owens 2020b). It is also important that
comparator was 'enhanced usual care' this consisted of little more adverse effects, both short- and long-term, are carefully evaluated.
than GP management (Kawanishi 2014). Whilst this may represent
enhanced usual care in that setting, it does not compare favourably Investigation of the mechanisms through which treatments
with TAU in a number of other studies of this intervention might work is also desirable to assist with the identification
approach (e.g. Clarke 2002). A positive step forward would be of clinically relevant subgroups of patients who may benefit
the operationalisation of TAU to inform both clinical practice and from certain, more intensive forms of intervention. For example,
research. It is possible that TAU has an advantage over some whilst CBT-based psychotherapy may have benefit in patients for
of these interventions because it offers more flexibility to tailor whom SH is predominately driven by depressive symptomatology
treatment to the specific needs of patients. (Gøtzsche 2017), more intensive forms of psychosocial intervention
(e.g. standard DBT, MBT, and possibly emotion-regulation
Results of this review would also suggest that, whilst case psychotherapy) may be more appropriate for those who engage in
management approaches did not appear to be effective frequent and repetitive SH in the context of a personality disorder,
in reducing the proportion of participants who repeat SH, particularly borderline personality disorder.
case management may increase engagement with subsequent
treatment whilst, additionally, enabling the identification of In trials where sex differences were examined, outcomes generally
psychosocial needs that should be addressed during treatment. favoured females (perhaps partly because mixed-sex trials included
A comprehensive therapeutic psychosocial assessment combined far more women than men, with consequent power issues for
with case management may have a potential role in encouraging examining outcomes in men). However, given that suicide following
individuals to attend for other types of therapy and therefore might SH is more common in men (Geulayov 2019; Carroll 2014), attention
be a useful part of a clinical intervention. This is in keeping with needs to be paid to the development of interventions that may
official guidance (NICE 2011). address the particular needs of men who engage in SH.
Implications for research There is a major need for further development and evaluation of
interventions in lower- and middle-income countries, particularly
The primary outcome of this review was repetition of SH at post- where psychiatric services may be limited. Such developments are
intervention to ensure consistency between the reviews in this suite likely to include remote contact and support interventions, which
of studies and, additionally, as this was the time point for which should be evaluated in large-scale trials, particularly as repetition
data were reported most consistently between the trials included of SH appears often to be less frequent than in Western settings
in this review. However, it is acknowledged that, in contrast to (Carroll 2014; Knipe 2019).
trials of pharmacological interventions (which is the subject of a
related review) where repetition of SH by post-intervention may Heed should also be paid to the principles of development
be the most appropriate choice, there is no consensus presently and evaluation of treatments, as laid out in the UK Medical
as to what time point(s) may be most appropriate for trials of Research Council guidance regarding complex interventions.
predominately psychosocial interventions. As the aim of many of Additionally, from a service planning perspective, future trials
these approaches is to equip patients with new skills that may should also include economic evaluations in order to determine
take time for them to master and use in dealing with future which interventions may be more feasible to routinely implement
crises, it may be unrealistic to expect benefits to be apparent throughout a health service (Bustamante-Madsen 2018).
immediately post-intervention. This may be particularly so for the
many brief intervention approaches we identified in this review. ACKNOWLEDGEMENTS
Longer follow-up assessments are therefore advisable. Given that
naturalistic studies of SH patients following discharge from services The authors thank the following trial authors for providing
would suggest that the risk of SH repetition and suicide may us with unpublished data: Anthony Bateman, Ryan Barnhart,
be greatest in the 12-months following discharge, peaking at Kirsten Barnicot, Annette Beautrais, Ram Pratap Beniwal, Olive
one-month post-discharge (Geulayov 2019; Gunnell 2008; Gilbody Bennewith, Greg Carter, Marie Cedereke, Tom Clarke, Mike
1997), assessments at these time points should be considered in Crawford, Kate Davidson, Elspeth Guthrie, Tony Fitzgerald,
future trials. Alexandra Fleischmann, Peter Fonagy, Kim Gratz, Anja Gysin-
Maillart, Melanie Harned, Simon Hatcher, Nusrat Husain, Nav
Given that SH results from a complex interplay between genetic, Kapur, Chiaki Kawanishi, Marsha Linehan, Rohana Marasinghe,
biological, psychiatric, psychosocial, social, cultural, and other Shelley McMain, David Owens, Stefan Priebe, Simon Schwab, Nadja
factors, the development of psychosocial interventions for SH in Slee, Priya Sreedaran, Carmen Stewart, Vojna Tapolaa, Barbara
adults could benefit from being based on detailed investigation of Tomenson, Peter Tyrer, Guillaume Vaiva, Lakshmi Vijayakumar,
these factors, including those that might enhance resilience that Carla Walton, August Wang, Igor Weinberg, and Dong Xu.
thereby reduces the risk of further SH, as well as having benefits for
other outcomes. The authors and the CCMD Editorial Team are also grateful to the
following peer reviewers for their time and comments: Kerry Dwan,
Additionally, trials of psychosocial interventions for adults who Sarah Fortune, Nick Meader and Jean Sellar-Edmunds. They would
engage in SH should include a range of outcome measures, not also like to thank Cochrane Copy Edit Support for the team's help
just SH and suicide, but also acceptability, adherence, and attitudes and Phil Roberts from the University of York for graphic design
to treatment by patients, their caregivers, and services providers support in the production of Figure 2 and 3.
as these may help to identify contributors to any apparent benefit
or lack of impact. In particular, the inclusion of outcomes that

Informed decisions.
This project was previously supported by the National Co- The NIHR is the largest single funder of the CCMD Group.
ordinating Centre for NHS Service Delivery and Organisation R&D
(NCCSDO). KH is funded by Oxford Health NHS Foundation Trust. The views expressed are those of the authors, and not necessarily
He is a National Institute for Health Research (NIHR) Senior those of the NHS, the NIHR, or the Department of Health and Social
Investigator, and personal funding from NIHR helped support this Care.
update.

Informed decisions.
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A novel brief therapy for patients who attempt suicide: a ACCESS study: Zelen randomised controlled after self-harm.
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Attempted Suicide Short Intervention Program (ASSIP). PLOS
One 2016;13:e1001968. Hatcher 2016 {published and unpublished data}
Hatcher S, Coupe N, Wikiriwhi K, Durie M, Pillai A. Te Ira Tangata:
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Cost-effectiveness of a brief structured intervention program
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Harned MS, Fitzpatrick S, Schmidt SC. Identifying change 2014;204:462-70.
targets for posttraumatic stress disorder among suicidal and
self-injuring women with borderline personality disorder. Hvid 2011 {published and unpublished data}
Journal of Traumatic Studies 2020;33(4):610-16. [DOI: 10.1002/ Hvid M, Vangborg K, Sørensen HJ, Nielsen IK, Stenborg JM,
jts.22504] Wang AG. Preventing repetition of attempted suicide- II: the
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protocol for suicidal and self-injuring women with borderline Kapur N, Gunnell D, Hawton K, Nadeem S, Khalil S, Longson D,
personality disorder and PTSD. Behaviour Research and Therapy et al. Messages from Manchester: pilot randomised controlled
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Hassanian-Moghaddam 2011 {published and unpublished data} 2013;203:73-4.
* Hassanian-Moghaddam H, Sarjami S, Kolahi A-A, Carter GL. Kawanishi 2014 {published and unpublished data}
Postcards in Persia: randomised controlled trial to reduce Furuno T, Nakagawa M, Hinto K, Tamada T, Kawashima Y,
suicidal behaviours 12 months after hospital-treated self- Matsuoka Y, et al. Effectiveness of assertive case management
poisoning. British Journal of Psychiatry 2011;198:309-16. on repeat self-harm in patients admitted for suicide attempt:
Hassanian-Moghaddam H, Sarjami S, Kolahi A-A, Lewin T, findings from ACTION-J study. Journal of Affective Disorders
Carter G. Postcards in Persia: a twelve to twenty-four month 2018;225:460-5.
follow-up of a randomized controlled trial for hospital- * Kawanishi C, Aruga T, Ishizuka N, Yonemoto N, Otsuka K,
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2017;21:138-54. usual care for people with mental health problems who had
Hatcher 2011 {published and unpublished data} attempted suicide and were admitted to hospital emergency
departments in Japan (ACTIONJ): a multicentre, randomised
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therapy for people who present to hospital with self-harm:
Zelen randomised controlled trial. British Journal of Psychiatry Norimoto K, Ikeshita K, Kishimoto T, Okuchi K, Yonemoto N,
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Informed decisions.
Liberman 1981 {published data only} Neacsiu AD, Lungu A, Harned MS, Rizvi SL, Linehan MM. Impact
Liberman RP, Eckman T. Behavior therapy vs insight-oriented of dialectical behavior therapy versus community treatment by
therapy for repeated suicide attempters. Archives of General experts on emotional experience, expression,and acceptance
Psychiatry 1981;38:1126-30. in borderline personality disorder. Behaviour Research and
Therapy 2014;53:47-54.
Lin 2020 {published data only (unpublished sought but not used)}
Secrist CD. The Role of Executive Functioning in the Treatment
Lin Y-C, Liu S-I, Chen S-C, Sun F-J, Huang H-C, Huang C-R,
of Borderline Personality Disorder. Seattle, WA: Department of
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case management for suicide attempters discharged from
the emergency department in Taipei, Taiwan: a randomized Linehan 2015 {published data only}
controlled study. Suicide and Life-Threatening Behavior
Kuehn KS, King KM, Linehan MM, Harned MS. Modeling the
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suicidal behavior cycle: understanding repeated suicide
Linehan 1991 {published data only} attempts among individuals with borderline personality
disorder and a history of attempting suicide. Journal of
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Consulting and Clinical Psychology 2020;88:570-81.
Cognitive-behavioral treatment of chronically parasuicidal
borderline patients. Archives of General Psychiatry Linehan MM, Korslund KE, Harned MS, Gallop RJ, Lungu A,
1991;48:1060-4. Neacsiu AD, et al. Dialectical behavior therapy for high suicide
risk in individuals with borderline personality disorder: a
Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of
randomized clinical trial and component analysis. JAMA
a behavioral treatment for chronically parasuicidal borderline
Psychiatry 2015;72:475-82.
patients. Archives of GeneralPsychiatry 1993;50:971-4.
Wilks CR, Korslund KE, Harned M, Linehan MM. Dialectical
Linehan 2006 {published and unpublished data}
behavior therapy and domains of functioning over two years.
Bedics JD, Atkins DC, Comtois JA, Linehan MM. Treatment Behaviour Research and Therapy 2016;77:162-9.
differences in the therapeutic relationship and introject during
a 2-year randomized controlled trial of dialectical behavior Linehan 2015a {published data only}
therapy versus non-behavioral psychotherapy experts for Linehan MM, Korslund KE, Harned MS, Gallop RJ, Lungu A,
borderline personality disorder. Journal of Consulting and Neacsiu AD, et al. Dialectical behavior therapy for high suicide
Clinical Psychology 2012;80:66-77. risk in individuals with borderline personality disorder: a
Bedics JD, Atkins DC, Harned MS, Linehan MM. The therapeutic
Psychiatry 2015;72:475-82.
alliance as a predictor of outcome in dialectical behavior
therapy versus nonbehavioral psychotherapy by experts Kuehn KS, King KM, Linehan MM, Harned MS. Modeling the
for borderline personality disorder. Psychotherapy: Theory, suicidal behavior cycle: understanding repeated suicide
Research and Practice 2015;52:67-77. attempts among individuals with borderline personality
Coyle TN, Shaver JA, Linehan MM. On the potential for
iatrogenic effects of psychiatric crisis services: the example of
dialectical behavior therapy for adult women with borderline Wilks CR, Korslund KE, Harned M, Linehan MM. Dialectical
personality disorder. Journal of Consulting and Clinical behavior therapy and domains of functioning over two years.
Psychology 2018;86:116-24. Behaviour Research and Therapy 2016;77:162-9.
Harned MS, Chapman AL, Dexter-Mazza ET, Murray A, Linehan 2015b {published data only}
Comtois KA, Linehan MM. Treating co-occurring axis I disorders
Linehan MM, Korslund KE, Harned MS, Gallop RJ, Lungu A,
in recurrently suicidal women with borderline personality
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disorder: a 2-year randomized trial of dialectical behavior
risk in individuals with borderline personality disorder: a
therapy versus community treatment by experts. Journal of
Psychiatry 2015;72:475-82.
Harned MS, Chapman AL, Dexter-Mazza ET, Murray A,
Kuehn KS, King KM, Linehan MM, Harned MS. Modeling the
Comtois KA, Linehan MM. Treating co-occurring axis I disorders
suicidal behavior cycle: understanding repeated suicide
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attempts among individuals with borderline personality
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therapy versus community treatment by experts. Personality
Disorders: Theory, Research and Treatment 2009;5:35-45.
Wilks CR, Korslund KE, Harned M, Linehan MM. Dialectical
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behavior therapy and domains of functioning over two years.
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follow-up of dialectical behavior therapy vs therapy by experts
for suicidal behaviors and borderline personality disorder.
Archives of General Psychiatry 2006;63:757-66.

Informed decisions.
Marasinghe 2012 {published and unpublished data} Stratton N, Mendoza Alvarez M, Labrish C, Barnhart R,
* Marasinghe RB, Edirippulige S, Kavanagh D, Smith A, McMain S. Predictors of dropout from a 20-week dialectical
Jiffry MTM. Effect of mobile phone-based psychotherapy in behavior therapy skills group for suicidal behaviors and
suicide prevention: a randomized controlled trial in Sri Lanka. borderline personality disorder. Journal of Personality Disorders
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Marasinghe RB. Evaluation of a Brief Inpatient and Community Morgan 1993 {published data only}
Intervention to Address Suicide Risk in Sri Lanka Using Morgan HG, Jones EM, Owen JH. Secondary prevention of non-
Mobile Phones [PhD thesis]. Brisbane, QLD: The University of fatal deliberate self-harm. The green card study. British Journal
Queensland, School of Medicine, 2012. of Psychiatry 1993;163:111-2.
McAuliffe 2014 {published and unpublished data} Morthorst 2012 {published data only}
McAuliffe C, McLeavey BC, Fitzgerald T, Corcoran P, Carroll B, Morthorst B, Krogh J, Erlangsen A, Alberdi F, Nordentoft M.
Ryan L, et al. Group problem-solving skills training for self- Effect of assertive outreach after suicide attempt in the
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2014;204:383-90. trial: randomised controlled trial. British Medical Journal
2012;345:e4972.
McLeavey 1994 {published data only}
McLeavey B, Daly R, Ludgate J, Murray C. Interpersonal Mouaffak 2015 {published data only}
problem-solving skills training in the treatment of self- Mouaffak F, Marchand A, Castaigne E, Arnoux A, Hardy P. OSTA
poisoning patients. Suicide and Life-Threatening Behavior program: a French follow up intervention program for suicide
1994;24:382-94. prevention. Psychiatry Research 2015;230:913-8.
McMain 2009 {published and unpublished data} Mousavi 2015 {published data only}
Boritz T, Barnhart R, McMain SF. The influence of posttraumatic Mousavi SG, Amini M, Mahaki B, Bagherian-Sarariudi R. Effect
stress disorder on treatment outcomes of patients with of phone call versus face-to-face follow-up on recurrent suicide
borderline personality disorder. Journal of Personality Disorders prevention in individuals with a history of multiple suicide
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management in the treatment of borderline personality Mousavi SG, Tehrani MN, Maracy M. The effect of active
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for suicide and self-harm behaviors in patients with
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outpatient psychotherapy. Journal of Personality Disorders
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intervention support programme for suicidal behaviour
McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. in a primary care setting. South African Family Practice
Dialectical behavior therapy compared with general psychiatric 2014;56:263-70.
management for borderline personality disorder: clinical
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outcomes and functioning over a 2-year follow-up. American
Journal of Psychiatry 2012;169:650-61. O'Connor SS, Comtois KA, Wang J, Russo J, Peterson R, Lapping-
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therapy versus general psychiatric management for borderline
personality disorder. American Journal of Psychiatry O'Connor 2017 {published data only}ISRCTN99488269
2009;166:1365-74. O'Connor RC, Ferguson E, Scott F, Smyth R, McDaid D, Park A-
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injury after 20-weeks of dialectical behaviour therapy group
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O'Connor SS, McClay MM, Choudhry S, Shields AD, Carlson R,
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Acta Psychiatrica Scandinavica 2017;135:138-48.

Informed decisions.
Owens 2020 {published data only}ISRCTN54036115 Torhorst 1987 {published data only}
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Priebe 2012 {published and unpublished data} Turner 2000 {published data only}
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Tyrer P, Thompson S, Schmidt U, Jones V, Knapp M, Davidson K,
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Vaiva 2006 {published data only}
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Slee 2008 {published and unpublished data} Vaiva 2018 {published data only}
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Sreedaran 2020 {published data only}
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Stewart 2009 {published and unpublished data} * Vaiva G, Berrouiguet S, Walter M, Courtet P, Ducrocq F,
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Tapolaa 2010 {published and unpublished data}
Van der Sande 1997 {published data only}
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Informed decisions.
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et al. Effect of crisis response planning vs. contracts for safety
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feasibility of the unified protocol in an inpatient setting.
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Psychiatry 2019;19:277. personality disorder: results from the borderline personality
disorder study of cognitive therapy (BOSCOT) trial. Journal of
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used)}
therapy v. usual treatment for borderline personality disorder:
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Informed decisions.
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Psychology and Psychotherapy: Theory, Research and Practice Gabilondo A, Aristegi E, Gonzalez-Pinto A, Zurimendi JM, Mateos
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al. The cost-effectiveness of cognitive behavior therapy for
Behavior 2020;50:211-9.
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used)}
Dimeff 2020 {published data only}
Galfalvy H, Brodsky B, Oquendo M, Stanley B. Childhood
Dimeff LA, Jobes DA, Chalker SA, Piehl BM, Duvivier LL,
maltreatment moderates antidepressant treatment response
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2020;63:119-26. Gooding 2020 {published data only}ISRCTN17776666
Di Simplicio 2020 {published data only} Gooding PA, Pratt D, Awenat Y, Drake R, Elliott R, Emsley R, et
al. A psychological intervention for suicide applied to non-
Di Simplicio M, Appiah-Kusi E, Wilkinson P, Watson P, Meiser-
affective psychosis: the CARMS (Cognitive AppRoaches to
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skills with interpersonal effectiveness skills and a control
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group treatment. Journal of Experimental Psychopathology
2015;6:369-88. Goodman 2020 {published data only}
Doering 2010 {published data only} Goodman M, Brown GK, Galfalvy HC, Page Spears A, Sullivan SR,
Kapil-Pair KN, et al. Group ("Project Life Force") versus
Buchheim A, Hörz-Sagstetter S, Doering S, Rentrop M,
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in borderline personality disorder: RCT study of transference-
focused psychotherapy. Psychotherapy and Psychosomatics Haddock 2019 {published data only (unpublished sought but not
2017;86:314-6. used)}ISRCTN17890126
* Doering S, Hörz S, Rentrop M, Fischer-Kern M, Schuster P, Awenat YF, Peters S, Gooding PA, Pratt D, Shaw-Núñez E,
Benecke C, et al. Transference-focused psychotherapy v. Harris K, et al. A qualitative analysis of suicidal psychiatric
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Ducasse D, Jaussent I, Arpon-Brand V, Vienot M, Laglaoui C,
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randomised controlled trial. Trials 2016;17:79.
management of suicidal patients: a randomized controlled trial.
Psychotherapy and Psychosomatics 2018;87:1-12. * Haddock G, Pratt D, Gooding PA, Peters S, Emsley R, Evans E,
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a controlled study. BMC Psychiatry 2017;17:96. Hashemi-Aliabadi S, Jalali A, Rahmati M, Salari N. Group
reminiscence for hope and resilience in care-seekers who have
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controlled trials. Journal of Consulting and Clinical Psychology self-criticism: does changing self-worth change pain endurance
2016;84:544-57.
Informed decisions.
in people who engage in self-injury. Clinical Psychological ISRCTN18761534 {unpublished data only}18761534
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Hooley 2018 {published data only}ISRCTN12276176
ISRCTN18761534 (first received 19 December 2012).
Hooley JM, Fox KR, Wang SB, Kwashie AND. Novel online daily
diary interventions for nonsuicidal self-injury: a randomized Jardon 2019 {published data only}
controlled trial. BMC Psychiatry 2018;18:264. Jardon V, Debien C, Duhem S, Morgiève M, Ducrocq F,
Vaiva G. An example of post-discharge monitoring after a
Hurtado-Santiago 2018 {published data only}
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Effectiveness of iconic therapy for the reduction of borderline 2019;45:S13-21.
personality disorder symptoms among suicidal youth: study
protocol for a randomised controlled trial. BMC Psychiatry Jobes 2017 {published data only}
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* Jobes DA, Comtois KA, Gutierrez PM, Brenner LA, Huh D,
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Prospective rates of suicide attempts and nonsuicidal self- Collaborative Assessment and Management of Suicidality
injury by young people with bipolar disorder participating in versus Enhanced Care As Usual with suicidal soldiers. Psychiatry
a psychotherapy study. Australian and New Zealand Journal of 2017;80:339-56.
Psychiatry 2015;50:167-73.
Johnson 2018 {published data only}
ISRCTN10115835 {unpublished data only}10115835
Johnson SB, Goodnight BL, Zhang H, Daboin I, Patterson B,
ISRCTN10115835. Is a talking therapy, called psychodynamic Kaslow NJ. Compassion-based mediation in African Americans:
interpersonal therapy, clinically and cost effective for women self-criticism mediates changes in depression. Suicide and Life-
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Intervention Pragmatic Trial (WORSHIP III)]. doi.org/10.1186/
ISRCTN10115835 (first received 11 February 2019). [DOI: Kawanishi 2018 {published data only}
10.1186/ISRCTN10115835] Kawanishi C, Ishii T, Yonemoto N, Yamada M, Tachikawa H,
Kishimoto T, et al. Protocol for a prospective multicentre
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self-harm in emergency departments [ASsuRED: Improving emergency department in Japan: Post-ACtion-J Study (PACS).
outcomes in patients who self-harm. Adapting and evaluating a British Medical Journal Open 2018;8:e020517.
brief pSychological inteRvention in Emergency Departments].
doi.org/10.1186/ISRCTN16003313 (first received 27 January Kennedy 2018 {published data only}
2020). Kennedy GA, Forney KJ, Pinner D, Martinez KM, Buchman-
Schmitt JM, Keel PK. Reducing anticipated non-suicidal self-
injury by improving body esteem in individuals with weight
ISRCTN16049211. FReSH START feasibility study [Function suppression: a proof of concept study. International Journal of
REplacement in repeated Self-Harm: Standardising Therapeutic Eating Disorders 2018;52:206-10.
Assessment and the Related Therapy (FRESH START): feasibility
study]. doi.org/10.1186/ISRCTN16049211 (first received 9 Kholodkov 2015 {published data only}
December 2019). Kholodkov T. Mindfulness-Based Relapse Prevention for Non-
Suicidal Self-Injury [Doctor of Philosophy thesis]. Laramie, WY:
University of Wyoming, 2015.
ISRCTN16862589. Brief education supported treatment for
adolescent borderline personality disorder [Brief Education Kim 2020 {published data only}
Supported Treatment (BEST) for adolescent borderline Kim M-H, Lee J, Noh H, Hong J-P, Kim P, Cha YS, et al.
personality disorder: a feasibility study of delivery of specialised Effectiveness of a flexible and continuous case management
early intervention for borderline personality disorder through program for suicide attempters. International Journal of
collaboration with education providers, incorporating a Environmental Research and Public Health 2020;17:2599.
feasibility randomised controlled trial]. doi.org/10.1186/
ISRCTN16862589 (first received 28 January 2019). Kline 2016 {published data only}
Kline A, Chesin M, Latorre M, Miller R, St Hill L, Shcherbakov A,
et al. Rationale and study design of a trial of mindfulness-based

Informed decisions.
cognitive therapy for preventing suicidal behavior (MBCT-S) in Matsubara 2019 {published data only}
military veterans. Contemporary Clinical Trials 2016;50:245-52. Matsubara T, Matsuo K, Matsuda A, Ogino Y, Hobara T,
Wakabayashi Y, et al. Combining phone and postcard brief
Korczak 2020 {published data only}
contact interventions for preventing suicide reattempts:
Korczak DJ, Finkelstein Y, Barwick M, Chaim G, Cleverley K, a quasi-randomized controlled trial. Psychiatry Research
Henderson J, et al. A suicide prevention strategy for youth 2019;279:395-6.
presenting to the emergency department with suicide related
behaviour: protocol for a randomized controlled trial. BMC McCall 2019 {published data only}
Psychiatry 2020;20:20. McCall WV, Ahn E, Benca R, Krystal A, Rosenquist PB,
Rumble M, et al. 0960. A preliminary report from the "REST-
LaCroix 2018 {published and unpublished data}
IT" study: insomnia severity and hypersomnia severity each
Ghahramanlou-Holloway M, LaCroix JM, Perera KU, Neely L, independently predict the intensity of suicidal ideation. Sleep
Grammer G, Weaver J, et al. Inpatient psychiatric care 2015;38:A339.
following a suicide-related hospitalization: a pilot trial of post-
admission cognitive therapy in a military medical center. * McCall WV, Benca RM, Rosenquist PB, Youssef NA, McCloud L,
General Hospital Psychiatry 2020;63:46-53. Newman JC, et al. REducing Suicidal ideation Through
Insomnia Treatment (REST-IT): a randomized clinical trial.
* LaCroix JM, Perera KU, Neely LL, Grammer G, Weaver J, American Journal of Psychiatry 2019;176:957-65.
Ghahramanlou-Holloway M. Pilot trial of post-admission
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Psychological Services 2018;15:279-88. McManama O'Brien KH, Sellers CM, Battalen AW, Ryan CA,
Maneta EK, Aguinaldo LD, et al. Feasibility, acceptability, and
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preliminary effects of a brief alcohol intervention for suicidal
Ghahramanlou-Holloway M. Post Admission Cognitive Therapy
adolescents in inpatient psychiatric treatment. Journal of
(PACT) for the prevention of suicide in military personnel with
Substance Abuse Treatment 2018;94:105-12.
histories of trauma: treatment development and case example.
Clinical Case Studies 2013;12:457-73. Miller 2016 {published data only}
Lahoz 2016 {published data only} Miller IW, Gaudiano BA, Weinstock LM. The Coping Long Term
with Active Suicide Program: description and pilot data. Suicide
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and Life-Threatening Behavior 2016;46:752-61.
suicide - III. The Amager Project, 5-year follow-up of a
randomized controlled trial. Nordic Journal of Psychiatry Morley 2014 {published data only}
2017;70:547-53.
Morley KC, Sitharthan G, Haber PS, Tucker P, Sitharthan T. The
Lin 2019 {published data only} efficacy of an Opportunistic Cognitive Behavioral intervention
package (OCB) on substance use and comorbid suicide risk: a
Lin T-J, Ko H-C, Wu KY-W, Oei TP, Lane H-Y, Chen C-H. The
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effectiveness of dialectical behavior therapy skills training
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group vs. cognitive therapy group on reducing depression and
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Archives of Suicide Research 2019;23:82-99.
Navarro-Haro MV, Botella C, Guillen V, Moliner R, Marco H,
Luxton 2014 {published data only} Jorquera M, et al. Dialectical behavior therapy in the treatment
of borderline personality disorder and eating disorders
Luxton DD, Thomas EK, Chipps J, Relova RM, Brown D, McLay R,
comorbidity: a pilot study in a naturalistic setting. Cognitive
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Therapy and Research 2018;42:636-49.
a multi-site randomized clinical trial in the U.S. military and
veteran affairs healthcare systems. Contemporary Clinical Trials NCT00218725 {unpublished data only}
2014;37:252-60.
NCT00218725. Cognitive therapy for suicide attempters
Mackie 2017 {published data only} with drug dependence disorder. clinicaltrials.gov/ct2/show/
NCT00218725 (first received 22 September 2005).
Mackie C, Dunn N, MacLean S, Testa V, Heisel M, Hatcher S. A
qualitative study of a blended therapy using problem solving NCT00601939 {unpublished data only}
therapy with a customised smartphone app in men who present
NCT00601939. Group interventions for abused, suicidal black
to hospital with intentional self-harm. Evidence Based Mental
women. clinicaltrials.gov/ct2/show/NCT00601939 (first received
Health 2017;20:118-22.
28 January 2008).
Marriott 2016 {published data only}
NCT00603421 {unpublished data only}
Marriott BP, Hibbeln JR, Killeen TK, Magruder KM, Holes-
NCT00603421. Effectiveness of a 24 hour phone line on the rate
Lewis K, Tolliver BK, et al. Design and methods for the Better
of suicide attempts in borderline patients. clinicaltrials.gov/ct2/
Resiliency Among Veterans and non-Veterans with Omega-3's
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(BRAVO) study: A double-blind, placebo-controlled trial of
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Informed decisions.
NCT00641498 {unpublished data only} NCT03376113 {unpublished data only}

NCT00641498. Effectiveness of standard emergency department NCT03376113. The effect of a brief psychological intervention
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emergency department psychiatric treatment associated clinicaltrials.gov/ct2/show/NCT03376113 (first received 18
with treatment delivery by a suicide prevention center. December 2017).
clinicaltrials.gov/ct2/show/NCT00641498 (first received 24
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NCT03489382. The BEACON Study: protocol for cluster RCT of a
NCT00980824 {published data only (unpublished sought but not service to deliver smartphone-assisted problem-solving therapy
used)} compared to usual care in men who present with intentional
NCT00980824. ENGAGE - Meeting mental health needs of self-harm to the ED in Ontario (protocol A). clinicaltrials.gov/ct2/
complex comorbid patients. clinicaltrials.gov/ct2/show/ show/NCT03489382 (first received 5 April 2018).
NCT00980824 (first received 21 September 2009).
NCT01359761 {unpublished data only} NCT03533075. A pilot effectiveness trial of the Teachable
NCT01359761. Post Admission Cognitive Therapy (PACT) Moment Brief Intervention (TMBI) for veterans hospitalized
for the inpatient treatment of military personnel with following a suicide attempt. clinicaltrials.gov/ct2/show/
suicidal behaviors: a multi-site randomized controlled trial. NCT03533075 (first received 22 May 2018).
clinicaltrials.gov/ct2/show/NCT01359761 (first received 25 May
2011). NCT03600532 {unpublished data only}
NCT03600532. Testing the efficacy of the Teachable Moment
NCT01823120 {unpublished data only} Brief Intervention for suicide attempt survivors in an inpatient
NCT01823120. Text message intervention to reduce repeat self- setting: effects on psychosocial and experimental pain
harm in patients presenting to the emergency department. outcomes. clinicaltrials.gov/ct2/show/NCT03600532 (first
clinicaltrials.gov/ct2/show/NCT01823120 (first received 4 April received 26 July 2018).
2013).
NCT01952405 {unpublished data only} NCT03943862. To Share or not to Share (2Share): group
NCT01952405. Efficacy of dialectical behavior therapy in intervention to support disclosure decisions after suicide
patients with borderline personality disorder: a controlled attempt. clinicaltrials.gov/ct2/show/NCT03943862 (first
trial in Taiwan. clinicaltrials.gov/ct2/show/NCT01952405 (first received 9 May 2019).
received 30 September 2013).
O'Toole 2019 {published data only}
NCT02227160 {unpublished data only} O'Toole MS, Arendt MB, Pedersen CM. Testing an app-assisted
NCT02227160. Group interventions for suicidal African treatment for suicide prevention in a randomized controlled
Americans. clinicaltrials.gov/ct2/show/NCT02227160 (first trial: effect on suicide risk and depression. Behavior Therapy
received 27 August 2014). 2019;50:421-9.
NCT02299440 {unpublished data only} Pearce 2017 {published data only}

NCT02299440. Effects of ketamine in the acute phase of suicidal Pearce S, Scott L, Attwood G, Saunders K, Dean M, De Ridder R,
ideation (KETIS). clinicaltrials.gov/ct2/show/NCT02299440 (first et al. Democratic therapeutic community treatment for
received 24 November 2014). personality disorder: randomised controlled trial. British
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NCT02522143. College students who self-harm: an intervention Pfeiffer 2019 {published data only}
study. clinicaltrials.gov/ct2/show/NCT02522143 (first received Lapidos A, Abraham KM, Jagusch J, Garlick J, Walters H,
13 August 2015). Kim HM, et al. Peer mentorship to reduce suicide attempts
among high-risk adults (PREVAIL): rationale and design of a
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NCT02742922. Multicenter RCT to evaluate the clinical and Contemporary Clinical Trials 2019;87:105850.
cost-effectiveness of a culturally adapted therapy (C-MAP) in
patients with a history of self-harm. clinicaltrials.gov/ct2/show/ * Pfeiffer PN, King C, Ilgen M, Ganoczy D, Clive R, Garlick J,
NCT02742922 (first received 19 April 2016). et al. Development and pilot study of a suicide prevention
intervention delivered by peer support specialists.
NCT03300596 {unpublished data only} Psychological Services 2019;16:360-71.
NCT03300596. Suicidal adults with alcohol or drug use
Philips 2018 {published data only}ISRCTN98982683
problems: a new hospital-based treatment. clinicaltrials.gov/
ct2/show/NCT03300596 (first received 3 October 2017). Philips B, Wennberg P, Konradsson P, Frank J. Mentalization-
based treatment for concurrent borderline personality disorder
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Informed decisions.
Pistorello 2020 {published data only} Ryberg W, Fosse R, Zahl P-H, Brorson I, Moller P, Landrø NI, et
Pistorello J, Jobes D, Compton S, Locey NS, Walloch JC, al. Collaborative Assessment and Management of Suicidality
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Treatment As Usual (TAU) for suicidal college students.
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Cognitive-behavioural suicide prevention for male prisoners:
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Alliant International University, 2018.
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* Indicates the major publication for the study
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Allard 1992
Study characteristics
Methods Participants were individually randomised using sealed and numbered envelopes to intensive outpa-
tient treatment or TAU.
N lost to follow-up: 24/150 (16.0%) for repetition of SH by the 24-month assessment.
Location: Montreal, Canada.
Participants Number of total participants: 150 participants were randomised, 76 were allocated to intensive outpa-
tient treatment and 74 were allocated to TAU.
Informed decisions.
Allard 1992 (Continued)

Profile of participants: mean (SD) age not reported. Just over half (n = 83; 55.3%) were female. Half (n =
75; 50.0%) had a history of SH (i.e. multiple episodes of SH). The majority were diagnosed with MDD (n =
131; 87.3%), followed by SUD (n = 80; 53.3%), and any personality disorder (n = 68; 45.3%).
Source of participants: patients presenting to hospital following a suicide attempt (i.e. SH with suicidal
intent).
Inclusion criteria: i) resident in the catchment area; ii) sufficient language ability (French or English); iii)
no physical handicap preventing attendance; iv) not already in institutional care; v) able to provide in-
formed consent; vi) not sociopathic; vii) suicide attempt within one week prior to trial entry.
Exclusion criteria: i) no fixed address; ii) moving out of the catchment area; iii) in the care of an insti-
tution that ensures follow-up after all suicide attempts; iv) diagnosed with a physical disability that
would prevent attendance at follow-up sessions; v) unable to provide informed consent; vi) diagnosed
with sociopathy and presents a physical threat to hospital personnel; vii) suicide attempt occurred over
one week preceding trial entry.
Interventions Intervention: intensive outpatient treatment consisting of 18 sessions (duration not reported), includ-
ing one delivered in the participants' home (delivered by a social worker). Sessions were weekly for the
first month, fortnightly for the next three months, and monthly for the remaining eight months. Thera-
peutic content included: developing a collaborative treatment plan and other various therapeutic ap-
proaches including psychoanalytically oriented psychotherapy, psychosocial therapy, AOD treatment,
or behavioural therapy as needed. At the conclusion of the 12-month treatment period, participants
were referred to usual psychiatric care. Sessions were delivered by a social worker (information on ex-
perience not reported).
Comparator: TAU consisting of treatment by the regular personnel within the same hospital (number
and duration of sessions not reported). Further information on therapeutic content not reported.
Length of treatment: 12 months.
Outcomes Primary outcome(s): i) repetition of SH according to hospital records, Coroner's records, and/or collat-
eral informant report.
Secondary outcome(s): i) treatment adherence as measured by the number of sessions attended; ii) sui-
cide as ascertained from Coroner's records and collateral informant report.
Notes Source(s) of funding: no information on funding reported.
Conflict(s) of interest: no information on conflicts of interest reported.
Amadéo 2015
Methods Participants were individually randomised using a block randomisation procedure.
N lost to follow-up: 10/200 (5.0%) by the post-intervention assessment.
Location: Papeete, Tahiti, French Polynesia.
Participants Number of total participants: 200 participants were randomised, 100 were allocated to provision of in-
formation and support and 100 were allocated to TAU.
Profile of participants: mean age 32.2 years (SD not reported, range not reported). Over half (n = 122;
64.2%) were female. Just over half (n = 97; 51.0%) were diagnosed with any mood disorder, followed by
any anxiety/adjustment disorder (n = 33; 17.4%), psychosis (n = 10; 5.3%), alcohol use disorder (n = 5;
2.6%), any personality disorder (n = 4; 2.1%), and cannabis use disorder (n = 2; 1.0%).
Source of participants: patients presenting to the ED following an episode of SH.

Informed decisions.
Amadéo 2015 (Continued)

Inclusion criteria: i) presenting to ED following an episode of SH.
Exclusion criteria: none reported.
Interventions Intervention: based on the SUPRE-MISS model (Fleischmann 2008), the intervention consisted of a brief
inpatient psychiatric admission (≥ 24 hours), a brief (one-hour) information session, and nine follow-up
telephone contacts (duration not reported) at weeks one, two, four, seven, 11, and months four, six, 12,
and 18 months post-discharge. No information on who delivered the intervention, their expertise, or
their experience was reported.
Comparator: TAU consisting of a brief inpatient psychiatric admission (≥ 24 hours), a single psychiatric
assessment (duration not reported), and then either hospitalisation, outpatient follow-up, or no care at
all.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report using the European Parasuicide
Study Interview Schedule (EPSIS); ii) suicide (as determined from Coroner's records).
Notes Source(s) of funding: "[T]he study was funded by the French Polynesia Ministry of Health and the Centre
Hospitalier de Polynésie Française" (Amadéo 2015, p.48).
Conflict(s) of interest: "[T]he authors declare no potential conflict of interest" (Amadéo 2015, p.48).
Andreoli 2015
Methods Participants were individually randomised using a pre-generated block randomisation procedure via
envelopes to either three months of abandonment psychotherapy delivered by certified psychothera-
pists, abandonment psychotherapy delivered by trained nurses, or TAU.
N lost to follow-up: 0/170 (0%) for repetition of SH at post-intervention.
Location: Geneva, Switzerland.
Participants Number of total participants: 170 participants were randomised, 70 were allocated to abandonment
psychotherapy delivered by certified psychotherapists, 70 were allocated to abandonment psychother-
apy delivered by trained nurses, and 30 were allocated to TAU.
Profile of participants: mean age 31.9 ± 10.1 years (range: 18 to 60 years). The majority (n = 143; 84.1%)
were female. All (n = 170; 100%) were diagnosed with BPD. The majority (n = 138; 81.2%) were also diag-
nosed with comorbid MDD, followed by SUD (n = 62; 36.5%).
Source of participants: patients presenting to the ED following an episode of SH requiring immediate

medical/surgical treatment.
Inclusion criteria: i) 18-60 years of age; ii) diagnosed with comorbid MDD and BPD according to DSM-IV
criteria.
Exclusion criteria: i) diagnosed with psychosis, bipolar I disorder, or severe SUD according to DSM-IV cri-
teria; ii) diagnosed with an intellectual disability; iii) diagnosed with an medical condition contraindi-
cated for antidepressant medication or likely to significantly alter clinical outcome(s); iv) insufficient
language ability.
Interventions Intervention 1: manualised abandonment psychotherapy delivered by certified psychotherapists. Aban-

donment psychotherapy consists of twice weekly sessions (duration not reported) incorporating princi-
ples from cognitive/psychodynamic therapy (e.g. cognitive restructuring), DBT (e.g. distress tolerance),
MBT (e.g. identification and labelling of different affective states), and family therapy. Sessions focus
on difficulties in romantic relationships. Participants also had access to a 24-hour crisis hotline as re-

Informed decisions.
Andreoli 2015 (Continued)

quired. Sessions were delivered by certified psychotherapists (information on experience was not re-
ported).
Intervention 2: manualised abandonment psychotherapy (as above) delivered by trained nurses with
experience in the management of patients diagnosed with BPD. Sessions were delivered by nurses with
considerable experience in managing patient with BPD.
Comparator: TAU. Consisting of as many nurse visits (duration not reported) as needed over a two-week
period, followed by biweekly nurse visits (duration not reported), weekly clinical and medication re-
view sessions (duration not reported), weekly group-therapy sessions (duration not reported), and as
many partial hospitalisations and family therapy sessions (duration not reported) as required for the
remainder of the treatment period.
Concomitant medications: were permitted. The majority (n = 125, 89.3%) were prescribed venlafaxine.
However, the proportion of participants prescribed an any antidepressant medication was lower in the
comparator arm (76.7%) compared with either of the intervention arms (97.1% and 97.1%, respective-
ly).
Length of treatment: three months.
Outcomes Primary outcome(s): i) clinical remission as measured by a Global Assessment Scale (GAS; Endicott
1976) score of > 60.
Secondary outcome(s): i) repetition of SH as ascertained from medical records; ii) symptom severity
as measured by a scores on the severity subscale of the Clinical Global Impression (CGI; Guy 1976); iii)
depression as measured by the HDRS; iv) remission from depression as ascertained from whether the
participant still meets DSM-IV criteria; iv) psychosocial outcome as measured by the HSRS; v) treat-
ment adherence as measured by the number of days retained in treatment and dropouts; vi) suicidal
ideation (unclear how ascertained); vii) all-cause hospitalisations as ascertained from medical records;
viii) suicide (unclear how ascertained).
Notes Source(s) of funding: no details on funding reported.
Conflict(s) of interest: no details on conflicts of interest reported.
Armitage 2016
Methods Participants were individually randomised using web-based software to either a guided implementa-
tion-focused intervention based on the volitional help-sheet model (Armitage 2016a), a self-directed
implementation intention-focused intervention (Armitage 2016b), or TAU.
N lost to follow-up: 0/226 (0%) for repetition of SH by the three-month assessment.
Location: Kuala Lumpur, Malaysia.
Participants Number of total participants: 226 participants were randomised, 78 were allocated to a brief, self-direct-
ed implementation intention intervention, 75 were allocated to a brief volitional help sheet interven-
tion, and 73 were allocated to TAU.
Profile of participants: mean age 30.0 ± 13.4 years (range: 15 to 65 years). The majority (n = 158; 69.9%)
were female.
Source of participants: admitted to a general hospital following an episode of SH.
Inclusion criteria: i) admitted to a general hospital following an episode of SH.

Informed decisions.
Armitage 2016 (Continued)
Interventions See Armitage 2016a and Armitage 2016b for a detailed description.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report using the Suicidal Behaviours Ques-
tionnaire; ii) suicidal ideation ascertained from self-report using the Suicidal Behaviours Questionnaire.
Secondary outcome(s): i) depression measured using the BDI; ii) motivation to avoid SH measured using
an idiosyncratic scale.
Notes Source(s) of funding: no information on sources of funding reported.
Conflict(s) of interest: none reported.
Armitage 2016a
Methods See Armitage 2016 for a detailed description.
Participants See Armitage 2016 for a detailed description.
Interventions Intervention (guided volitional help-sheet): one-off (duration not reported) session. Participants are pro-
vided with a list of common situations in which they may be tempted to engage in SH together with
a list of potential alternative behaviours. Participants then draw links between any situation that ap-
plies to them and any one of the listed alterative behaviours. Participants can make as many links as
desired. No information on who delivered the intervention, their expertise, or their experience was re-
ported.
Comparator: TAU. No further information reported.
Length of treatment: one-off session (duration not reported).
Outcomes See Armitage 2016 for a detailed description.
Notes See Armitage 2016 for a detailed description.
Armitage 2016b
Methods See Armitage 2016 for a detailed description.
Participants See Armitage 2016 for a detailed description.
Interventions Intervention (self-directed implementation intention): one-off (duration not reported) session in which
participants were free to formulate their own safety plan. Sessions were self-delivered.
Comparator: TAU. No further information reported.
Length of treatment: one-off session (duration not reported).
Outcomes See Armitage 2016 for a detailed description.
Notes See Armitage 2016 for a detailed description.

Informed decisions.
Bateman 2009
Methods Participants were individually randomised using a stochastic minimisation programme

(MINIM) balanced for age (18-25, 26-30, and > 30 years), sex, and diagnosis of ASPD to MBT or structured
case management.
N lost to follow-up: 2/136 (1.5%) for repetition data at post-intervention.
Location: London, UK.
Participants Number of total participants: 134 participants were randomised, 71 were allocated to MBT and 63 were
allocated to structured case management.
Profile of participants: mean age 31.1 ± 7.7 years (range: 18-65 years). The majority (n = 107; 79.9%) were
female. All (n = 134; 100%) had a history of SH (i.e. multiple episodes of SH). Just over three-quarters
(n = 103; 76.9%) were diagnosed with a milder depressive disorder such as dysthymia, followed by any
anxiety disorder (n = 82; 61.2%), SUD (n = 72; 53.7%), any eating disorder (n = 37; 27.6%), PTSD (n = 19;
14.2%), and somatoform disorder (n = 17; 12.7%). Just over one-quarter (n = 37; 27.6%) were diagnosed
with comorbid ASPD.
Source of participants: consecutive referrals to one of two community outpatient psychiatric facilities,
one of which provides specialist treatment for PD.
Inclusion criteria: i) 18-65 years of age; ii) diagnosed with BPD; iii) engaged in SH within six months prior
to trial entry.
Exclusion criteria: i) currently in long-term psychotherapeutic treatment; ii) diagnosed with any psy-
chosis or bipolar I disorder according to DSM-IV criteria; iii) dependent on any opiate to such a degree
that specialist AOD treatment is indicated; iv) diagnosed with a mental impairment or evidence of an
organic brain disorder.
Interventions Intervention: manualised MBT consisting of up to 140 sessions (duration not reported) of weekly indi-
vidual and group therapy. Therapeutic content also included: collaborative crisis planning, a general
psychiatric review every three months, case management, advocacy support, and problem-oriented
psychotherapy. Sessions were delivered by therapists (no further information on expertise or experi-
ence was reported).
Comparator: structured case management designed to analogue TAU consisting of three-monthly in-
dividual and group therapy (duration not reported). Therapeutic content was based on a counselling
model resembling a supportive approach and included: counselling, case management, and prob-
lem-oriented psychotherapy.
Concomitant medication(s): participants were prescribed medication (e.g. antidepressants,

antipsychotics, mood stabilisers, minor tranquillisers), as needed. As baseline, just under three-quar-
ters (n = 98; 73.1%) were prescribed concomitant medications (mean number of medications pre-
scribed at baseline: 1.1 ± 0.9).
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) repetition of suicide attempts (un-
clear how ascertained); iii) hospital readmission (unclear how ascertained).
Secondary outcome(s): i) general functioning as measured by the GAF; ii) distress as measured by the
Global Severity Index (GSI); iii) depression as measured by the BDI; iv) social functioning as measured
by the Social Adjustment Scale (SAS); v) interpersonal functioning as measured by the Inventory of In-
terpersonal Problems (IIP); vi) medication use (unclear how ascertained).
Notes Source(s) of funding: “Supported by a grant from the Borderline Personality Disorder Research Founda-
tion” (Bateman 2009, p. 1363).
Informed decisions.
Bateman 2009 (Continued)

Other: data on repetition of SH, suicide attempts, and suicides were obtained via correspondence with
trial authors.
Beautrais 2010
Methods Participants were individually randomised using a predetermined computer-generated random num-
ber procedure to a remote contact intervention (postcards) or TAU.
N lost to follow-up: 0/327 (0) for repetition of SH data.
Location: Christchurch, New Zealand.
Participants Number of total participants: 327 participants were randomised, 153 were allocated to the remote con-
tact intervention and 174 were allocated to TAU.
Profile of participants: mean age 33.8 (SD: not reported; range: 18-65 years). Two thirds (n = 216; 66.0%)
were female. Fifty-eight (17.7%) had a history of SH (i.e. multiple episodes of SH). No information on
psychiatric diagnoses was reported.
Source of participants: patients admitted to a psychiatric emergency service following an episode of SH

or attempted suicide.
Inclusion criteria: i) 16 years of age or older; ii) admitted to a psychiatric emergency service following an
episode of SH or attempted suicide; iii) resident in New Zealand; iv) sufficient language ability.
Interventions Intervention: remote contact intervention consisting of postcards mailed at two and six weeks and
three, six, nine, and 12 months post-discharge in addition to TAU. Postcards encouraged participants to
make contact with the service if required. No information on who delivered the intervention, their ex-
pertise, or their experience was reported.
Comparator: TAU consisting of crisis assessment and referral to inpatient community-based

mental health services as required.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from emergency service records and medical
records; ii) representation to psychiatric emergency services as ascertained from emergency service
records and medical records.
Secondary outcome(s): i) suicide (unclear how ascertained).
Notes Source(s) of funding: "This study was supported by grants from the Canterbury District Health Board
and the Accident Compensation Corporation (ACC). S.J.G. was supported by a University of Otago Post-
graduate Publishing Bursary" (Beautrais 2010, p. 59).

Other: data on suicides were obtained via correspondence with trial authors.
Bennewith 2002

Informed decisions.
Bennewith 2002 (Continued)
Methods cRCT. GP practices were randomised, stratified by rate of SH, via a random numbers trial to either a GP
letter or TAU.
N lost to follow-up: 0/1932 (0%) for repetition of SH data.
Location: Avon, Wiltshire, and Somerset, UK.
Participants Number of total participants: 1932 participants were allocated, 964 were allocated to GP management
and 968 were allocated to TAU.
Profile of participants: mean age 32.5 ± 13.2 years (range: 16-95 years). Just over half (n = 1140; 59.0%)
were female. A minority (n = 244; 12.6%) had a history of SH (i.e. multiple episodes of SH) according to
case register information. No information on psychiatric diagnoses was reported.
Source of participants: patients presenting to hospital following an episode of SH and who were also
registered with one of the participating primary care practices.
Inclusion criteria (for GP practices): i) located in catchment area (i.e. within catchment area of the four
recruitment general hospitals).
Inclusion criteria (for participants): i) aged 16 years and older; ii) data able to be found in general hospi-
tal case register; iii) recruitment data able to be collected weekly from hospitals’ A&E sites; iv) fixed res-
idence.
Exclusion criteria: i) engaged in an alcohol only or illicit drug overdose (except where casualty offi-
cer felt purpose was SH or suicide); ii) imprisoned; iii) made a request that no one be informed of SH
episode; iv) SH occurred in direct response to a hallucination or delusion; v) SH episode managed en-
tirely in primary care.
Interventions Intervention: letter from GP inviting patient to a consultation with GP (provided with management
guideline). Sessions were delivered by GPs (no information on experience was reported).
Comparator: TAU consisting of GP management, psychiatric, or other referral, as required.
Length of treatment: one-off consultation.
Outcomes Primary outcome(s): i) repetition of SH ascertained from hospital case registers.
Secondary outcome(s): i) frequency of SH repetition ascertained from hospital case registers; ii) time to
first repeat SH episode ascertained from hospital case registers; iii) contact with services (unclear how
ascertained).
Notes Source(s) of funding: "National Health Service South West Research and Development Direc-
torate" (Bennewith 2002, p. 1260).
Conflict(s) of interests: none reported.
Brown 2005
Methods Participants were individually randomised using a computer-generated sequence (designed to prohibit
more than seven consecutive assignments to the same treatment group) to either CBT or EUC.
N lost to follow-up: 18/120 (15.0%) for repetition by the six-month follow-up assessment.
Location: Pennsylvania, USA.
Participants Number of total participants: 120 participants were allocated, 60 were allocated to CBT and 60 were al-
located to TAU.

Informed decisions.
Brown 2005 (Continued)

Profile of participants: mean age 35.0 ± 10.2 years (range: 18-66 years). Over half (n = 73; 60.8%) were
female. The majority (n = 87; 72.5%) had a history of SH (i.e. multiple episodes of SH). Just over three-
quarters were diagnosed with MDD (n = 92; 76.7%), followed by SUD (n = 82; 68.3%).
Source of participants: patients presenting to hospital following a suicide attempt.
Inclusion criteria: i) 16 years of age or older; ii) engaged in a suicide attempt and received medical/psy-
chiatric evaluation within 48 hours of the attempt; iii) able to provide at least two verifiable contacts;
iv) sufficient language ability; v) able to complete baseline assessment; vi) able to provide informed
consent.
Exclusion criteria: i) diagnosed with any medical condition that would prevent participation in an out-
patient clinical trial.
Interventions Intervention: CBT-based psychotherapy consisting of 10 weekly/biweekly sessions (duration not report-
ed) in addition to TAU. Therapeutic content included: identification of proximal thoughts, core beliefs,
development of alternative coping strategies, and relapse prevention. Therapy focused on hopeless-
ness, deficits in problem-solving, treatment noncompliance, and social isolation. Sessions were deliv-
ered by trial therapists (no further information on expertise or experience was reported).
Comparator: TAU, including referral to other services, as required.
Length of treatment: 10-20 weeks (exact duration not clearly reported).
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report; ii) depression as measured using
the HDRS and BDI; iii) hopelessness as measured by the BHS; iv) suicidal ideation as measured by the
BSSI.
Secondary outcome(s): i) treatment adherence (this outcome had to be excluded from the review due to
the nature of the data reported).
Notes Source(s) of funding: "This research was supported by grants R01 MH60915 and P20 MH71905 from the
National Institute of Mental Health and grant R37 CCR316866 from the Centers for Disease Control and
prevention" (Brown 2005, p. 570).
Carter 2005
Methods Participants were individually randomised using Zelen's post-consent design to a remote contact inter-
vention in addition to TAU or TAU alone.
N lost to follow-up: 0/772 (0%) for repetition of SH data.
Location: Hunter Valley, NSW, Australia.
Participants Number of total participants: 772 participants were allocated, 378 were allocated to a remote contact
intervention (postcards) in addition to TAU and 394 were allocated to TAU alone.
Profile of participants: median age 33.0 years (IQR: 24.0 to 44.0 years; range: not reported). Over two-
thirds (n = 525; 68.0%) were female. A minority (n = 131; 17.0%) had a history of SH (i.e. multiple
episodes of SH). Just under half (n = 333; 43.1%) were diagnosed with any mood disorder, followed by
SUD (n = 311; 40.3%), and any PD (n = 169; 21.9%).
Source of participants: patients presenting to hospital toxicology service following an episode of self-
poisoning.

Informed decisions.
Carter 2005 (Continued)

Inclusion criteria: i) 16 years of age or older; ii) presented to a toxicology service following an episode of
deliberate self-poisoning; iii) able to provide informed consent; iv) fixed address; v) sufficient language
ability; vi) did not pose a potential threat to the interviewer.
Interventions Intervention: remote contact intervention consisting of a series of postcards mailed at one, two, three,
four, six, eight, 10 and 12 months' post-discharge in addition to TAU. Postcards encouraged partici-
pants to make contact with the service if required. No information on who delivered the intervention,
their expertise, or their experience was reported.
Comparator: TAU.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from electronic hospital records.
Notes Source(s) of funding: “KC is funded by the NSW Health, Burdekin Mental Health Enhancement Strate-
gy” (Carter 2005, p. 4).
Other: data on suicides obtained following correspondence with the trial authors. Additionally, 20 con-
trol group participants received intervention due to clerical errors but were included by the authors in
the control group for all intention-to-treat analyses.
Cedereke 2002
Methods Participants were individually randomised using sealed envelopes to a remote contact intervention
(telephone contact) in addition to TAU or TAU alone.
N lost to follow-up: 44/216 (20.4%) for repetition of SH by the 12-month follow-up assessment.
Location: Lund, Sweden.
intervention (telephone contact) in addition to TAU and 109 were allocated to TAU alone.
Profile of participants: mean age 41.0 ± 18.0 years (range: not reported). Almost two-thirds (n = 143;
66.2%) were female. Just over half (n = 112; 51.8%) had a history of SH (i.e. multiple episodes of SH).
The majority (n = 197; 91.2%) were diagnosed with a mood disorder.
Source of participants: patients treated in hospital following a suicide attempt (i.e. with evidence of sui-
cidal intent).
Inclusion criteria: i) received treatment in a general hospital following a suicide attempt.
Interventions Intervention: remote contact intervention consisting of a two telephone contacts (20-45 minutes) at
four and eight months' post-discharge in addition to TAU. Telephone calls were designed to offer moti-
vational therapy and to encourage participants to remain adherent to TAU. Sessions were delivered by
therapists (no information on expertise reported) with a minimum of 10 years' experience working with
suicidal persons.
Comparator: TAU.

Informed decisions.
Cedereke 2002 (Continued)

Length of treatment: eight months.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report and medical records; ii) suicide
as ascertained from mortality registers.
Secondary outcomes: i) general functioning as measured by the GAF; ii) distress as measured by the
Symptom Check List-90 (SCL-90) and the GSI; iii) suicidal ideation as measured by the BSSI; iv) treat-
ment adherence as measured by the number of telephone contacts made.
Notes Source(s) of funding: “This study was supported by grants from The Axson Johnsons foundation and
from the Vardal Foundation (V97 341)” (Cedereke 2002, p. 90).
Conflict(s) of interest: no information reported.
Clarke 2002
Methods Participants were individually randomised using a random numbers list, stratified by sex and admitting
hospital, to case management in addition to TAU or TAU alone.
Location: East London and Essex, UK.
Participants Number of total participants: 467 participants were allocated, 220 were allocated to case management
in addition to TAU and 247 were allocated to TAU alone.
Profile of participants: mean age 33.0 (SD not reported; range: not reported). Over half (n = 263; 56.3%)
were female. One in five (n = 104; 22.3%) had a history of SH (i.e. multiple episodes of SH). A minority
were diagnosed with any psychiatric disorder (n = 80; 17.1%); most commonly AUD (n = 60; 75.0%) fol-
lowed by schizoaffective disorder (n = 12; 2.5%).
Source of participants: patients presenting to hospital following SH.
Inclusion criteria: i) aged 16 years or older; ii) resident in the catchment area; iii) overdose attributable
to recreational or problematic substance use.
Exclusion criteria: i) aged less than 16 years; ii) between 16 and 19 years and still in full-time secondary
education; overdose attributable to recreational or problematic substance use.
Interventions Intervention: case management comprising a comprehensive assessment of individual needs, develop-
ment of an individualised package of care, arrangement of access to services, monitoring of quality of
services provided, and long-term, flexible support. Number of sessions and their duration not reported.
Participants also received TAU. Sessions were delivered by a case manager (no further information on
expertise or experience was reported).
Comparator: TAU comprising triage, and medical and psychosocial treatment, as required.
Length of treatment: up to six months.
Outcomes Primary outcome(s): i) repetition of SH according to hospital admission records; ii) suicide (unclear how
ascertained).
Notes Source(s) of funding: "Funded by the participating health authority” (Clarke 2002, p. 167).

Other: data on suicides obtained following correspondence with trial authors.

Informed decisions.
Crawford 2010
Methods Participants were individually randomised using a random numbers table to a brief, alcohol-focused in-
tervention or TAU.
N lost to follow-up: 0/103 (0%) for repetition of SH by the six-month assessment; 65/103 (63.1%) for sec-
ondary outcomes not included in this review (e.g. alcohol consumption, mental health problems, and
satisfaction with treatment).
Participants Number of total participants: 103 participants were allocated, 51 were allocated to the brief alcohol-fo-
cused intervention and 52 were allocated to TAU alone.
Profile of participants: mean age 37.2 ± 12.0 years (range: 18-65 years). Almost half (n = 50; 48.5%) were
female. All (n = 103; 100%) were diagnosed with AUD.
Source of participants: consecutive admissions to an ED following an episode of SH and who were diag-
nosed with alcohol misuse according to scores on the Paddington Alcohol Test.
Inclusion criteria: i) aged 18 years or older; ii) admitted to an ED following an episode of SH; iii) diag-
nosed with alcohol misuse according to scores on the Paddington Alcohol Test.
Exclusion criteria: i) unwilling to provide informed consent; ii) unable to provide informed consent
(e.g. due to insufficient language ability or impaired consciousness); iii) no fixed address in the greater
London area; iv) already receiving treatment from AOD services; v) made a specific request to receive
treatment from AOD services at the index presentation.
Interventions Intervention: one-off appointment (~30 minutes) with an alcohol nurse specialist involving assessment
and discussion of both current and previous drinking behaviours delivered according to the FRAMES
approach in addition to a health information leaflet advising on the damaging effects of excessive al-
cohol consumption, recommended limits of alcohol consumption, and the contact details of nation-
ally-based alcohol misuse help lines (Miller 1993). Participants could also be referred by the alcohol
nurse specialist to individual alcohol counselling or detoxification services as required. Sessions were
delivered by an alcohol nurse specialist (no further information on experience was reported).
Comparator: TAU comprising a health information leaflet advising on the damaging effects of excessive
alcohol consumption, recommended limits of alcohol consumption, and the contact details of nation-
ally-based alcohol misuse help lines.
Length of treatment: 30 minutes.
Outcomes Primary outcome(s): i) repetition of SH according to hospital records.
Secondary outcome(s): i) levels of alcohol consumption as measured by the Alcohol Use Disorders Iden-
tification Test (AUDIT); ii) diagnosis of probable personality disorder as ascertained by a score of ≥ 3 on
the Standardised Assessment of Personality - Abbreviated Scale (SAPAS); iii) general mental health as
measured by the General Health Questionnaire-12 (GHQ-12); iv) satisfaction with treatment as mea-
sured by the Client Satisfaction Questionnaire; v) suicide (unclear how ascertained).
Notes Source(s) of funding: “This study was funded by St Mary’s Paddington Charitable Trust” (Crawford 2010,
p. 1827).
Conflict(s) of interest: none stated.
Other: data on suicides were obtained following correspondence with trial authors.

Informed decisions.
Davidson 2014
Methods Participants were individually randomised (2:1 ratio) using a random numbers table to manualised
CBT-based psychotherapy or TAU.
N lost to follow-up: 6/20 (30.0%) for repetition of SH by the three-month assessment.
Location: Glasgow, UK.
Participants Number of total participants: 20 participants were allocated, 14 were allocated to CBT-based psy-
chotherapy and 6 were allocated to TAU.
Profile of participants: mean (SD) age not reported (range: 18-65 years). Proportion female not report-
ed. All (n = 20; 100%) were diagnosed with a personality disorder; most commonly BPD (n = 17; 85.0%),
followed by avoidant PD (n = 13; 65.0%), and paranoid PD (n = 8; 40.0%). Almost half (n = 9; 45.0%) were
diagnosed with a comorbid SUD.
Source of participants: patients admitted to the medical receiving ward of the A&E department follow-
ing an episode of SH.
Inclusion criteria: i) aged 18-65 years; ii) diagnosed with any PD according to the SCID-II; iii) score of ≥ 3
on the Standardised Assessment of Personality Abbreviated Scale.
Exclusion criteria: i) unwilling or unable to provide informed consent.
Interventions Intervention: brief, manualised CBT-based psychotherapy consisting of six sessions (duration not re-
ported). Therapeutic content included: psychoeducation, development of alternatives to resolving
problems, and referral to appropriate mental health services, where required. Sessions were delivered
either by a doctoral-level clinical psychologist or a psychiatrist who received training (duration not re-
ported) in manualised CBT-based psychotherapy and ongoing weekly supervision.
Comparator: TAU consisting of referral to community mental health teams, appointments with psychia-
trists and a community psychiatric nurse, and inpatient psychiatric treatment, as required. Information
on both the number and duration of sessions was not reported.
Length of treatment: not reported.
Outcomes Primary outcome(s): i) repetition of SH according to self-report using the Acts of Deliberate Self-Harm
Inventory (DSHI); ii) suicidal ideation as measured by the BSS; iii) depression as measured by the HADS;
iv) alcohol consumption as measured by the AUDIT; v) psychiatric treatment as ascertained from elec-
tronic medical records.
Notes Source(s) of funding: "This work was supported by NHS Greater Glasgow and the Scottish Mental Health
Research Network” (Davidson 2014, p. 4).
Dubois 1999
Methods Participants were individually randomised; however, the method used was not reported.
Location: Bohars, France.

Informed decisions.
Dubois 1999 (Continued)
Profile of participants: mean age 22.4 ± 5.8 years (range: not reported). The majority (n = 82; 80.4%) were
female. Over half (n = 57; 55.9%) were diagnosed with any mood disorder, followed by any anxiety dis-
order (n = 44; 43.1%), psychosis (n = 43; 42.1%), and SUD (n = 14; 13.7%). A minority were not diagnosed
with any psychiatric disorder (n = 13; 12.7).
Source of participants: patients attending the ED following a suicide attempt.
Inclusion criteria: i) aged 15-34 years; ii) presented to the ED following a suicide attempt.
Exclusion criteria: i) hospitalised for more than 24 hours; ii) currently being treated by a psychiatrist.
Interventions Intervention: brief CBT-based psychotherapy consisting of five sessions (duration not reported). Whilst
these sessions followed a specific therapeutic model, the therapeutic content was not reported. Ses-
sions were delivered by the same therapist who initially saw them in the hospital (no further informa-
tion on who delivered the intervention, their expertise, or their experience was reported).
Comparator: TAU involving an assessment and follow-up by a clinical psychiatrist.
Length of treatment: one month.
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) suicide (unclear how ascertained);
iii) treatment adherence as measured by the number of sessions attended.
Notes Source(s) of funding: no information reported.
Conflict(s) of interest: no information reported.
Other: As data on treatment adherence were not reported for the control group, this outcome had to be
excluded from subsequent analyses.
Evans 1999a
Methods Participants were individually randomised using sealed envelopes to either a remote contact interven-
tion (emergency card) or TAU.
Location: Bristol, UK.
intervention and 410 were allocated to TAU.
Profile of participants: mean age 33.3 ± 13.0 years (range: not reported). Just over half (n = 458; 55.4%)
were female. Just under half (n = 349; 42.2%) had a history of SH (i.e. multiple episodes of SH). The ma-
jority (n = 707; 85.5%) were diagnosed with a psychiatric disorder; however, no specific information on
these diagnoses was reported. One hundred and twenty (14.5%) did not have a psychiatric diagnosis.
Source of participants: patients admitted to general hospital following an episode of SH.
Inclusion criteria: i) admitted to the ED following an episode of SH; ii) referred for routine psychiatric
evaluation; iii) resident in catchment area; iv) judged likely to use intervention appropriately; v) made
contact with and used mental health services; vi) acceptable level of aggressive behaviour.

Informed decisions.
Evans 1999a (Continued)

Exclusion criteria: i) inappropriate substance abuse leading to repetitive presentation in which the par-
ticipant was aggressive; ii) unable to engage in treatment.
Interventions Intervention: remote contact intervention (emergency card) in addition to TAU. Participants were pro-
vided with an emergency card offering 24-hour service for crisis telephone consultation with an on-call
psychiatrist. Sessions were delivered by the duty trainee psychiatrist (no further information on experi-
ence was reported).
Comparator: TAU.
Length of treatment: six months.
Outcomes Primary outcome(s): i) repetition of SH ascertained from A&E and hospital records; ii) suicide (unclear
how ascertained).
Notes Source(s) of funding: “Funding was provided by a grant from the Department of Health” (Evans 1999a, p.
23).
Conflict(s) of interest: none stated.
Evans 1999b
Methods Participants were individually randomised using sealed envelopes opened sequentially to either CBT-
based psychotherapy or TAU.
N lost to follow-up: 2/34 (5.9%) for repetition of SH by the six-month assessment.
Profile of participants: mean (SD) not reported (range: 16 to 50 years). Over half (n = 21; 61.8%) were fe-
male. All (n = 34; 100%) had a history of SH (i.e. multiple episodes of SH). All (n = 34; 100%) were diag-
nosed with a PD.
Source of participants: patients admitted to 1 of 2 hospitals in the London area (Paddington and
Chelsea, Westminster) following an episode of SH.
Inclusion criteria: i) diagnosed with any PD (ASPD, dissocial, impulsive or BPD); ii) ≥ 1 episode of SH in
12 months preceding trial entry.
Exclusion criteria: i) diagnosed with alcohol or drug dependence, schizophrenia, or organic psychiatric
disorder.
Interventions Intervention: two to six sessions (duration not reported) of manual-assisted CBT. Therapeutic content
included: basic cognitive techniques (e.g. cognitive restructuring), problem-solving, distress tolerance,
identification and management of emotions and thoughts, identification of alternative coping strate-
gies, and relapse prevention. Sessions were delivered by a psychiatrist, community mental health team
member, or social workers with experience (duration not reported) working with persons who engage
in SH.
Comparator: TAU. Five participants had contact with a psychiatrist, three saw a community mental
health team, four saw a specialist social worker, and two saw no mental health professional.
Length of treatment: varied.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report and hospital records.

Informed decisions.
Evans 1999b (Continued)

Secondary outcome(s): i) time to repetition of SH as ascertained from self-report and hospital records;
ii) social functioning as measured by the Social Functioning Questionnaire; iii) depression as measured
by the depression subscale of the HADS; iv) anxiety as measured by the anxiety subscale of the HADS;
v) treatment adherence as measured by the number of sessions attended; vi) health economics evalua-
tion.
Notes Source(s) of funding: “This work was supported by a grant from the North Thames Regional Health Au-
thority” (Evans 1999b, p. 24).
Conflict(s) of interest: no information on author interests reported.
Other: five participants in the intervention arm did not see a therapist and instead received therapy
from the booklets. One participant in the intervention arm did not receive any intervention.
Fleischmann 2008
Methods Participants were individually randomised using a random numbers table to either provision of infor-
mation and support or TAU.
N lost to follow-up: 204/1867 (10.9%) for repetition of SH by the post-intervention assessment.
Locations: Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Iran; Yuncheng, China.
Participants Number of total participants: 1867 participants were allocated, 922 were allocated to information and
support and 945 were allocated to TAU.
Profile of participants: median 23.0 years (IQR not reported; range: not reported). Over half (n = 1086;
58.2%) were female. Around one in five (n = 394; 21.1%) had a history of SH (i.e. multiple episodes of
SH). No information reported on psychiatric diagnoses.
Source of participants: patients presenting to emergency care settings following an episode of SH/self-
poisoning within a defined catchment area with a population of at least 250,000 persons.
Inclusion criteria: i) presenting to services following an episode of SH/self-poisoning as determined by

medical staff.
Exclusion criteria: i) died on the ward; ii) presence of a clinical condition that would preclude interview;
iii) left hospital against medical advice; iv) resident in a different catchment area; v) insufficient lan-
guage ability.
Interventions Intervention: brief, one-off intervention involving “information about suicidal behaviour as a sign of
psychological and/or social distress, risk and protective factors, basic epidemiology, repetition, alter-
natives to suicidal behaviours, and referral options” (Fleischmann 2008, p. 705) (duration: one hour)
and contact via telephone or home visits to provide referral support in addition to TAU for up to 18
months. The number and duration of these telephone contacts was not reported. Sessions were deliv-
ered by trained psychiatrists, medical doctors, psychologists, or psychiatric nurses (no information on
experience was reported).
Comparator: TAU “according to the norms prevailing in the respective emergency departments” (Fleis-
chmann 2008, p. 704). This typically involved only acute treatment for somatic problems only.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report using the European Parasuicide
Study Interview Schedule (EPSIS); ii) suicide (unclear how ascertained).
Secondary outcome(s): i) anger as measured by the Spielberger Trait-Anger Scale; ii) depression as
measured by the BDI; iii) hopelessness as measured by the BHS; iv) impulsiveness as measured by the
Eysenck Impulsiveness Scale; v) social support as measured by the Bille-Brahe Measurement of Social
Support; vi) suicidal intent as measured by the Beck Suicide Intent Scale; vii) treatment adherence as

Informed decisions.
Fleischmann 2008 (Continued)

measured by the number of sessions attended; viii) well-being as measured by the WHO Well-Being In-
dex.
Notes Source(s) of funding: “The study was funded by the Department of Mental Health and Substance Abuse,
WHO. Some field research sites obtained additional funding from the following agencies: Campinas:
Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), grant no 02/08288-9, São Paulo,
Brazil; Durban: Medical Research Council (MRC), Tygerberg, Cape Town, South Africa; Karaj: Tehran
Psychiatric Institute, Mental Health Research Centre (IUMS), Tehran, Iran; Tallinn: Estonian Health In-
surance Fund, Tallinn, Estonia; the Swedish National and Stockholm County Centre for Suicide Re-
search and Prevention of Mental Ill-Health (NASP), WHO Collaborating Centre for Research and Train-
ing in Suicide Prevention, Department of Public Health Sciences, Karolinska Institute, Stockholm, Swe-
den” (Fleischmann 2008, p. 708).
Gibbons 1978
Methods Correspondence with trial authors confirmed participants were individually randomised using sequen-
tially numbered envelopes to either CBT-based psychotherapy or TAU.
N lost to follow-up: 0/400 (0%) for repetition of SH by the 12-month follow-up assessment.
Location: Southampton, UK.
Profile of participants: mean (SD) age not reported (range: not reported). The majority (n = 284; 71.0%)
were female. A mix of both first-time and those with a history of multiple episodes of SH were included,
however, information on the proportion of each was not reported. Under half (n = 176; 44.0%) were di-
agnosed with a depressive disorder, followed by an anxiety disorder (n = 8; 2.0%), affective psychosis (n
= 8; 2.0%), and schizophrenia (n = 4; 1.0%). Diagnoses for the remaining four (1.0%) participants not re-
ported.
Source of participants: patients presenting to A&E following an episode of self-poisoning,
Inclusion criteria: i) 17 years of age or older; ii) presented to A&E following an episode of self-poisoning.
Exclusion criteria: i) at immediate suicide risk; ii) not formally diagnosed with a psychiatric disorder.
Interventions Intervention: CBT-based psychotherapy consisting of sessions (both the number and duration not re-
ported) of a time-limited, crisis-oriented, task-entered programme delivered by social workers. Thera-
peutic content involved problem-solving focused on personal and social relationships, identifying al-
ternative coping strategies, and distress tolerance. Sessions were delivered by qualified and experi-
enced (duration not reported) social workers.
Comparator: TAU. Just over half (n = 108; 54.0%) were referred to their GP, one-third (n = 66; 33.0%)
were referred to psychiatric services, and 26 (13.0%) received an unspecified referral.
Outcomes Primary outcome(s): i) repetition of SH as according to hospital records; ii) depression as measured by
the BDI; iii) social functioning as measured by an idiosyncratic scale; iv) treatment satisfaction accord-
ing to self-report.
Notes Source(s) of funding: “The study was supported by the Department of Health and Social Security, and
the Wessex Regional Health Authority” (Gibbons 1978, p. 117).
Conflict(s) of interests: no information reported.

Informed decisions.
Gratz 2006
Methods Participants were individually randomised using an unspecified method to either group-based emotion
regulation therapy or TAU.
N lost to follow-up: 2/24 (8.3%) for repetition of SH data by the post-intervention assessment.
Location: Boston, MA, USA.
Participants Number of total participants: 24 participants were allocated, 13 were allocated to group-based emotion
regulation therapy and 11 were allocated to TAU.
Profile of participants: mean age 33.3 ± 12.2 (range: 18 to 60 years). All (n = 24; 100%) were female, had a
history of SH (i.e. multiple episodes of SH), and were diagnosed with BPD.
Source of participants: clinician referrals and self referrals from advertisements posted at a hospital
and on two websites. All had engaged in an episode of SH presenting to clinical services within the six
months preceding trial entry.
Inclusion criteria: i) diagnosed with BPD; ii) history of SH resulting in presentation to clinical services,
with ≥ 1 episode in the six months preceding trial entry; iii) have an individual therapist; iv) aged 18 to
60 years; v) female.
Exclusion criteria: i) diagnosed with psychosis, bipolar I disorder, or SUD; ii) at immediate suicide risk
(i.e. made a suicide attempt rated as having a ’high’ risk of death or greater within the six months pre-
ceding trial entry); iii) at risk of attempting suicide within the next year; iv) received DBT in the six
months preceding trial entry.
Interventions Intervention: group-based emotion regulation psychotherapy consisting of weekly (duration not report-
ed) sessions. Therapeutic content is drawn from Acceptance and Commitment Therapy (ACT), DBT, and
emotion-focused therapy and includes: psychoeducation, identification of emotions, distress toler-
ance, emotional acceptance, behavioural activation, developing alternative coping strategies, impulse
control, and identifying and clarifying valued directions. Participants also received weekly (one hour)
sessions of individual therapy and TAU. The average number of hours spent in TAU per week was 2.1 ±
1.6. Sessions were delivered by therapists (no further information on expertise or experience was re-
ported).
Comparator: TAU consisting of weekly (more than one hour) sessions of individual therapy. In addition
to individual therapy almost two-thirds (32%) attended group-based psychotherapy, and 9% attended
self-help groups (e.g. AA, NA). The average number of hours spent in TAU per week was 2.9 ± 2.8.
Length of treatment: 14 weeks.
Outcomes Primary outcome(s): i) repetition of SH according to self-report using the DSHI; ii) anxiety as measured
by the anxiety subscale of the DASS; iii) BPD symptomatology as measured by the Borderline Evalua-
tion of Severity over Time (BEST); iv) depression as measured by the depression subscale of the DASS;
v) emotion regulation as measured by the DERS; vi) emotional avoidance as measured by the Accep-
tance and Action Questionnaire (AAQ); vii) stress as measured by the stress subscale of the DASS.
Notes Source(s) of funding: ”This research was supported by the Psychosocial Fellowship of McLean Hospital,
awarded to the first author“ (Gratz 2006, p. 25).
Conflict(s) of interests: Although no author interests were reported, Prof Gratz developed emotion regu-
lation group therapy.

Informed decisions.
Gratz 2014
Methods Participants were individually randomised, stratified by age, emotion dysregulation, number of lifetime
episodes of SH, and GAF scores to either group-based emotion regulation therapy or TAU.
N lost to follow-up: 0/61 (23.5%) for repetition of SH data by the post-intervention assessment.
Location: Jackson, MS, USA.
Participants Number of total participants: 61 participants were allocated, 31 were allocated to group-based emotion
regulation therapy and 30 were allocated to TAU.
Profile of participants: mean age 33.2 ± 10.9 (range: 18 to 60 years). All (n = 61; 100%) were female, and
had a history of SH. Over half (n = 38; 62.3%) were diagnosed with any anxiety disorder, half (n = 31;
50.0%) were diagnosed with any mood disorder, followed by PTSD (n = 22; 36.0%), any eating disorder
(n = 8; 13.3%), and SUD (n = 1; 1.6%).
Source of participants: referrals from clinicians to the emotion regulation group therapy and from self
referrals in response to an advertisement posed both online and in the community. All had engaged in
an episode of SH presenting to clinical services within the six months preceding trial entry.
Inclusion criteria: i) aged 18-60 years; ii) females; iii) diagnosed with threshold or subthreshold BPD; iv)
history of repeated SH with ≥ 1 episode in the six months prior to trial entry; v) have one or more of the
following: individual therapist, psychiatrist, case manager.
Exclusion criteria: i) diagnosed with psychosis or bipolar I disorder; ii) current (past month) substance
use.
Interventions Intervention: manualised group-based (maximum of six participants per group) emotion regulation
psychotherapy consisting of weekly (90 minutes) sessions. Therapeutic content is drawn from Accep-
tance and Commitment Therapy (ACT), DBT, and emotion-focused therapy and includes: psychoedu-
cation, identification of emotions, distress tolerance, emotional acceptance, behavioural activation,
developing alternative coping strategies, impulse control, and identifying and clarifying valued direc-
tions. Participants also received weekly (one hour) sessions of individual therapy and TAU. The average
number of hours spent in TAU per week was 2.1 ± 1.6. Sessions were delivered by doctoral-level thera-
pists who received a minimum of four months training in delivering group-based emotion regulation
psychotherapy.
Comparator: TAU consisting of weekly (more than one hour) sessions of individual or group-based ther-
apy. Few participants (18%) received group-based therapy, however. Most (> 70%) were receiving sup-
portive or dynamic individual therapy, 19% were receiving CBT, none were receiving DBT.
Outcomes Primary outcome(s): i) repetition of SH according to self-report using the DSHI and the Self-Harm Inven-
tory (SHI); ii) BPD symptomatology as measured by the Zanarini Rating Scale for Borderline Personality
Disorder (ZAN-BPD) and the BEST; iii) depression as measured by the BDI and the depression subscale
of the DASS.
Secondary outcome(s): i) emotion regulation as measured by the DERS; ii) emotional avoidance as mea-
sured by the AAQ; iii) interpersonal problems as measured by the BPD-related composite of the Inven-
tory of Interpersonal Problems (IIP-BPD); iv) quality of life as measured by the Quality of Life Inventory;
v) social functioning as measured by the Sheehan Disability Scale (SDS).
Notes Source(s) of funding: “This research was supported by National Institute of Mental Health Grant R34
MH079248, awarded to Dr. Gratz” (Gratz 2014, p. 2110).
Conflict(s) of interests: Although no author interests were reported, Prof Gratz developed emotion regu-
lation group therapy.

Informed decisions.
Grimholt 2015
Methods Participants were individually randomised to either structured GP management or TAU.
N lost to follow-up: 6/149 (4.0%) for repetition of SH at the post-intervention assessment according to
hospital records, or 26/149 (17.5%) according to emergency department records.
Location: Oslo and Akershus County, Norway.
Participants Number of total participants: 202 participants were randomised, 101 were allocated to structured GP
follow-up and 101 were allocated to TAU. However, data on repetition of SH were only available for
analysis for up to 59.4% of those allocated to the intervention arm and 82.2% of those allocated to TAU.
Profile of participants: mean age 38.2 (SD not reported; range: 18 to 75 years). Just under three-quarters
(n = 111; 74.5%) were female. Over one-third (n = 58; 38.9%) had a history of SH (i.e. multiple episodes
of SH). Information on psychiatric diagnoses were not reported.
Source of participants: patients admitted to the acute medical wards of any of five hospitals following
an episode of self-poisoning.
Inclusion criteria: i) 18-75 years of age; ii) admitted to the acute medical ward following an episode of
self-poisoning.
Exclusion criteria: i) diagnosed with psychosis, an intellectual disability, or organic cognitive impair-
ment; ii) insufficient language ability; iii) not registered with a GP (includes non-native citizens); iv) re-
ferred for inpatient psychiatric or other (e.g. AOD) treatment.
Interventions Intervention: structured GP follow-up consisting of one follow-up GP appointment within one-
week post-discharge, one GP consultation per month for the first three months of the intervention
(i.e. months one to three), and two further GP consultations in the final three months of the interven-
tion (i.e. months four to six). Sessions were delivered by GPs (no further information on experience re-
ported).
Comparator: referral to outpatient psychiatric, AOD, and/or family counselling, as needed. TAU did not
preclude GP management.
Outcomes Primary outcome(s): i) suicidal ideation as measured by the BSSI.
Secondary outcome(s): i) depression as measured by the BDI; ii) hopelessness as measured by the BHS;
iii) repetition of SH as ascertained from self-report supplemented by medical records.
Notes Source(s) of funding: "The trial was funded by the Norwegian Southern Eastern Health Authority and the
Regional Centre of Traumatic Stress and Suicide Prevention, Eastern Norway" (Grimholt 2015, pp.1-2).
Conflict(s) of interest: "The authors have declared that no competing interests exist" (Grimholt 2015,
p.2).
Guthrie 2001
Methods Participants were individually randomised using a computer-generated list to either CBT-based psy-
chotherapy or TAU.
N lost to follow-up: 0/119 (0%) for repetition of SH by the six-month assessment.

Informed decisions.
Guthrie 2001 (Continued)

Location: Manchester, UK.
Profile of participants: mean age 31.2 ± 1.5 (range: not reported). Just over half (n = 66; 55.5%) were fe-
male, had a history of SH (i.e. multiple episodes of SH) (n = 71; 59.7%), and a history of previous psychi-
atric treatment (n = 65; 54.6%); however, information on psychiatric diagnoses was not reported.
Source of participants: patients presenting to hospital after an episode of self-poisoning most common-
ly involving acetaminophen/paracetamol (n = 43; 36.1%).
Inclusion criteria: i) aged 18-65 years; ii) presenting with episode of self-poisoning; iii) sufficient lan-
guage ability; iv) living in the catchment area; v) registered with a GP.
Exclusion criteria: i) requiring immediate psychiatric treatment.
Interventions Intervention: individual CBT-based psychotherapy consisting of weekly (50 minute) sessions of home-
based psychodynamic interpersonal therapy. Therapeutic content included: resolving interpersonal
difficulties causing distress through a conversational approach, identification of feelings and relating
these to problems and relationships, and developing shared understanding and approaches to resolv-
ing family problems. Sessions were delivered by nurse therapists (no further information on experience
was reported).
Comparator: TAU. In most cases, this involved assessment by doctor in the ED and referral to psychiatry
outpatient treatment, addiction services, or GP, where required.
Outcomes Primary outcome(s): i) suicidal ideation as measured using the BSSI.
Secondary outcome(s): i) repetition of SH as ascertained by self-report supplemented by hospital

records; ii) depression as measured using the BDI; iii) service use as ascertained from records; iv) treat-
ment satisfaction as measured by an idiosyncratic scale; v) suicide (unclear how ascertained).
Notes Source(s) of funding: “North West Regional Health Authority and the NHS Research and Development
Levy” (Guthrie 2001, p. 4).
Gysin-Maillart 2016
Methods Participants were individually randomised using Zelen's post-consent method to either 24 months of a
CBT-based program (ASSIP) in addition to a remote contact intervention or TAU.
Location: Bern, Switzerland.
Participants Number of total participants: 120 participants were randomised, 60 were allocated to the multi-compo-
nent ASSIP program and 60 were allocated to TAU.
Profile of participants: mean age 38.2 ± 14.0 years; range: 18 to 75 years). Over half (n = 66; 55.0%) were
female. Half (n = 60; 50.0%) had a history of SH (i.e. multiple episodes of SH). Most (n = 76; 63.3%) were
diagnosed with any mood disorder, followed by SUD (n = 30; 25.0%), and any PD (n = 20; 16.7%).
Source of participants: patients admitted to the ED for an episode of SH.

Informed decisions.
Gysin-Maillart 2016 (Continued)

Inclusion criteria: i) referred for in- or outpatient treatment; ii) sufficient language ability; iii) able to pro-
vide written informed consent.
Exclusion criteria: i) diagnosed with psychosis; ii) in custody or imprisoned; iii) insufficient language
ability.
Interventions Intervention: mixed multimodal intervention (CBT-based program together with a remote contact). The
Attempted Suicide Short Intervention Program (ASSIP) comprises three weekly sessions (60-90 min-
utes) comprising cognitive case conceptualisation based on a vulnerability-trigger model, psychoed-
ucation, collaborative safety planning, and relapse prevention. A fourth session (60-90 mins) can be
added as necessary. Participants also receive personalised letters at 1, 3, 6, 9, 12, 18, and 24 months'
post-discharge. Sessions were delivered by psychiatrists, psychologists, and other therapists with an
average of two years experience working with suicidal persons and who received training (one week) in
delivering ASSIP.
Comparator: TAU comprising a one-off structured risk assessment, a summary of which was sent to the
participant's usual care coordinator.
Concomitant medications: were permitted. Around half were prescribed antidepressants (n = 56;
46.7%), followed by antipsychotics (n = 21; 17.5%), tranquillisers (both major and minor; n = 15; 12.5%),
and other medications (not specified; n = 13; 10.8%).
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report supplemented by collateral infor-
mants (e.g. GPs) and medical records.
Secondary outcome(s): i) suicidal ideation as measured by the BSSI; ii) healthcare utilisation (unclear
how measured); iii) depression as measured by the BDI; iv) therapeutic alliance as measured by the
Penn Helping Alliance Questionnaire; v) suicide as ascertained from collateral informants (e.g. GPs) and
medical records.
Notes Source(s) of funding: "The authors received no specific funding for this work (Gysin-Maillart 2016, p.1).
Conflict(s) of interest: "KM and AGM received royalties from Hogrefe Publishing for "ASSIP—At-
tempted Suicide Short Intervention Program: A Manual for Clinicians. K. Michel & A. Gysin-Maillart
(2015)" (Gysin-Maillart 2016, p.1).
Harned 2014
Methods Participants were individually randomised using a minimisation procedure stratified for number of sui-
cide attempts/episodes of NSSI (past year), PTSD symptom severity, dissociative symptom severity,
and current use of any SSRI to either DBT (prolonged-exposure protocol) or DBT (standard protocol).
N lost to follow-up: 8/26 (30.8%) for repetition of SH data at the post-intervention assessment.
Location: Seattle, WA, USA.
Participants Number of total participants: 26 participants were allocated, 19 were allocated to DBT (prolonged pro-
tocol) and 7 were allocated to DBT (standard protocol).
Profile of participants: mean age 32.6 ± 12.0 (range: 19-55 years). All (n = 26; 100%) were female, and
were diagnosed with comorbid PTSD and BPD.
Source of participants: patients seeking treatment from a specialist treatment service for suicidal indi-
viduals with comorbid BPD and PTSD.

Informed decisions.
Harned 2014 (Continued)

Inclusion criteria: i) female; ii) aged 18-60 years; iii) diagnosed with BPD; iv) diagnosed with PTSD; v) has
satisfactory recall of at least part of the index trauma; vi) recent and recurrent SH (i.e. ≥ 2 suicide at-
tempts or episodes of NSSI in the previous five years, with ≥ 1 within the eight weeks preceding trial en-
try); vii) lives within commuting distance.
Exclusion criteria: i) diagnosed with psychosis, bipolar disorder, or mental retardation; ii) receiving
treatment under legal mandate; iii) require treatment for another life-threatening condition (e.g.
anorexia nervosa).
Interventions Intervention: DBT (prolonged-exposure protocol) consisting of either one combined individual therapy
session per week (90 minutes) or two individual therapy sessions per week delivered by the same ther-
apist (90 min), one group-based skills session (60 minutes), and telephone consultation, as required.
Therapeutic content was the same as standard DBT and included: identification of emotions, targeting
problems that may occur during or as a result of exposure to trauma, targeting trauma-related shame,
dialectics, irreverence, self-disclosure, and validation. Sessions were delivered by masters-level clini-
cians (doctoral-level students in training, licensed professionals, or postdoctoral fellows) with an aver-
age of two years of clinical experience and who received training (one day) in delivering DBT.
Comparator: standard DBT consisting of either one combined individual therapy session per week (30
minutes) or two individual therapy sessions per week delivered by the same therapist (60 minutes), one
group-based skills session (60 minutes), and telephone consultation, as required. Therapeutic content
was the same as above.
Concomitant medication(s): were permitted, however, "...patients on SSRIs were asked to either taper
off the medication before starting...or remain at a constant dose..." (Harned 2014, p.10).
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report using the SASII; ii) PTSD symp-
toms as measured by the PSS-I.
Secondary outcome(s): i) anxiety as measured by the Hamilton Rating Scale for Anxiety (HRSA); ii) de-
pression as measured by the HDRS; iii) dissociative experiences as measured by the Dissociative Expe-
riences Scale-Taxon (DES-T); iv) general psychological well-being as measured by the GSI; v) shame as
measured by the Experience of Shame Scale (ESS); vi) trauma-related guilt cognitions as measured by
the Trauma- Related Guilt Inventory (TRGI).
Notes Source(s) of funding: “This work was supported by grant R34MH082143 from the National Institute of
Mental Health” (Harned 2014, p. 16).
Conflict(s) of interest: “Drs. Harned, Korslund, and Linehan are trainers and consultants for Behavioral
Tech, LLC” (Harned 2014, p. 16).
Hassanian-Moghaddam 2011
Methods Participants were individually randomised using a blocking procedure and a random numbers table to
either a remote contact intervention (postcards) in addition to TAU or TAU alone.
N lost to follow-up: 187/2300 (8.1%) for repetition of SH at post-intervention.
Location: Tehran, Iran.
Participants Number of total participants: 2300 participants were allocated, 1150 were allocated to the remote con-
tact intervention (postcards) and 1150 were allocated to TAU.
Profile of participants: mean age 24.1 ± 8.1 years (range: not reported). Over half (n = 1402; 66.4%) were
female. Just under one-third (n = 723; 31.4%) had a history of SH (i.e. multiple episodes of SH). No infor-
mation was reported on psychiatric diagnoses.

Informed decisions.
Hassanian-Moghaddam 2011 (Continued)

Source of participants: patients admitted or transferred to a specialist hospital for the treatment of poi-
soning following an episode of self-poisoning.
Inclusion criteria: i) aged 12 years or older; ii) admitted or transferred to a specialist hospital for the
treatment of poisoning following an episode of self-poisoning.
Exclusion criteria: i) treated in the ED of a general hospital; ii) diagnosed with psychosis; iii) unable to
provide informed consent (e.g. due to insufficient language ability); iv) no fixed address; v) posed a po-
tential threat to interviewers; vi) episode of self-poisoning was classified by the attending toxicologist
as recreational, habitual, accidental, or iatrogenic.
Interventions Intervention: remote contact intervention consisting of a series of postcards mailed at one, two, three,
four, six, eight, 10 and 12 months' post-discharge in addition to TAU. Postcards encouraged partici-
pants to make contact with the service, if required. No information on who delivered the intervention,
their expertise, or their experience was reported.
Comparator: TAU. Although no specific details were provided, the authors noted that “[f ]ollow-up care
for self-poisoning in Tehran is generally poor...Contact is mainly hospital- or office-based, and commu-
nity-based programs are almost non-existent. Psychiatric beds are often at 100% occupancy, with short
admissions and frequent readmissions.” (Hassanian-Moghaddam 2011, pp. 310-311).
Outcomes Primary outcome(s): i) repetition of SH according to self-report supplemented by hospital records; ii)
suicidal ideation (according to self-report).
Secondary outcome(s): i) suicide (unclear how ascertained); ii) treatment adherence as ascertained
by the number receiving the postcard; iii) satisfaction with treatment as ascertained by the number
reporting the postcard was useful in the prevention of SH; iv) all-cause mortality (unclear how ascer-
tained).
Notes Source(s) of funding: “This study was supported by a grant from the Legal Medicine Organization of Iran
and the Loghman-Hakim Research Development Unit, Shahid Beheshti Medical University” (Hassan-
ian-Moghaddam 2011, p. 315).
Hatcher 2011
Methods Participants were individually randomised using a computer-generated numbers list and Zelen's
method to either CBT-based psychotherapy in addition to TAU or TAU alone.
N lost to follow-up: 0/552 (0%) (of those consenting) by for repetition of SH by the 12-month assess-
ment.
Location: Auckland and Wellington, New Zealand.
Profile of participants: mean age 33.7 ± 12.9 years (range: not reported). Over two-thirds (n = 380; 68.8%)
were female. Just under half (n = 247; 44.7%) had a history of SH (i.e. multiple episodes of SH).
Source of participants: patients admitted to hospital following an episode of SH.
Inclusion criteria: i) aged 16 years or older; ii) admitted to hospital following an episode of SH.

Informed decisions.
Hatcher 2011 (Continued)

Exclusion criteria: i) enrolled full time in school; ii) receiving DBT for the treatment of BPD; iii) have a
treatment management plan which precludes short-term therapy; iv) cognitively impaired; v) admitted
to a psychiatric care unit following the index episode of SH for a minimum period of 48 hours.
Interventions Intervention: manualised CBT-based psychotherapy based on D'Zurilla 1971 consisting of up to nine (60
minutes) sessions of PST. Therapeutic content included: problem orientation, problem listing and defi-
nition, brainstorming, devising an action plan, and reviewing the plan. Sessions were delivered by clini-
cians (social workers, psychotherapists, counselling and health psychologists) who did not have exten-
sive experience working in mental health settings and who received training (one week) in delivering
problem-solving psychotherapy.
Comparator: TAU involving a one-off psychosocial assessment by a mental health professional, as well
as referral to multidisciplinary teams for psychiatric or psychological intervention, referral to men-
tal health crisis teams, recommendations for engagement with AOD centres or other health and non-
health services, as required.
Outcomes Primary outcome(s): i) repetition of SH according to hospital records; ii) time to repetition of SH accord-
ing to hospital records.
Secondary outcome(s): i) anxiety as measured by the anxiety subscale of the HADS; ii) depression as
measured by the depression subscale of the HADS; iii) hopelessness as measured by the BHS; iv) social
functioning as measured by the Social Problem-Solving Inventory Scale (SPSI); v) suicidal ideation as
measured by the BSS: vi) suicide (ascertained from Coroner's records).
Notes Source(s) of funding: “This study was funded by the Accident Compensation Corporation of New
Zealand” (Hatcher 2011, p. 316).
Hatcher 2015
Methods Participants were individually randomised using a computer-generated sequence, stratified by history
of SH and method of SH, using Zelen's method, to either a multimodal intervention or TAU.
N lost to follow-up: 0/1474 (0%) (of those consenting) for repetition of SH by the post-intervention as-
sessment.
Location: Waitemata, Manukau, Northland, and Waikato regions, New Zealand.
Participants Number of total participants: 684 participants were allocated, 327 were allocated to the multimodal in-
tervention and 357 were allocated to TAU.
Profile of participants: mean age 36.8 ± 14.4 (range: not reported). Over half (n = 464; 67.8%) were fe-
male and had a history of SH (i.e. multiple episodes of SH) (n = 370; 54.1%). Information on psychiatric
diagnoses not reported.
Inclusion criteria: i) presented to the ED following an episode of SH.
Exclusion criteria: i) aged less than 17 years; ii) enrolled full time in school; iii) unable to provide in-
formed consent; iv) self-identifies as Māori (these participants were instead invited to participate in the
Hatcher 2016 trial).
Interventions Intervention: multimodel intervention consisting of one to two face-to-face or telephone patient sup-
port sessions (duration not reported) over the fortnight following discharge from hospital to ensure pa-

Informed decisions.

tients were adhering to their agreed discharge plan; four to six sessions (duration not reported) of PST
(based on D'Zurilla 1971) in the four weeks following the index SH episode; postcards mailed at one,
two, three, four, six, eight, 10 and 12 months following the index SH episode; improved access to prima-
ry care via the provision of a voucher that could be used to access one free GP consultation (duration
not reported); development of a risk management strategy; and a cultural assessment focused on iden-
tifying patients’ sense of belonging and identification with their ethnic group. Sessions were delivered
by research clinicians (no further information on their expertise or experience was reported).
Comparator: TAU consisting of referral to multidisciplinary teams for psychiatric/psychological assess-

ment, intervention, or both; referral to crisis teams; or referral to community-based AOD treatment
teams, as required.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from electronic medical records.
Secondary outcome(s): i) repetition of SH as ascertained from self-report; ii) anxiety as measured by the
anxiety subscale of the HADS; ii) belonging as measured by the Sense of Belonging Instrument; iii) de-
pression as measured by the depression subscale of the HADS; iv) hopelessness as measured by the
BHS; v) quality of life as measured by the EQ-5D; vi) service use as measured by self-report supplement-
ed by electronic medical records; vii) suicide (unclear how ascertained).
Notes Source(s) of funding: none reported.

Hatcher 2016
Methods Participants were individually randomised using a computer-generated sequence, stratified by history
of SH and method of SH, using Zelen's method, to either a multimodal intervention or TAU.
N lost to follow-up: 0/365 (0%) for repetition of SH by the post-intervention assessment.
Location: Waitemata, Manukau, and Northland regions, New Zealand.
Participants Number of total participants: 365 participants were allocated, 182 were allocated to the multimodal in-
tervention and 183 were allocated to TAU.
Profile of participants: mean age 32.3 ± 10.7 (range: not reported). Over two-thirds (n = 109; 65.3%) were
female, and over half (n = 100; 59.9%) had a history of SH (i.e. multiple episodes of SH). Information on
psychiatric diagnoses not reported.
Inclusion criteria: i) presented to the ED following an episode of SH; ii) self-identifies as Māori; iii) suffi-
cient language ability to communicate in te reo Maori (Māori language).
Exclusion criteria: i) aged less than 17 years; ii) enrolled full time in school; iii) unable to provide in-
formed consent.
Interventions Intervention: culturally-adapted multimodel intervention consisting of one to two face-to-face or tele-
phone patient support sessions (duration not reported) over the fortnight following discharge from
hospital to ensure patients were adhering to their agreed discharge plan; four to six sessions (duration
not reported) of PST (based on D'Zurilla 1971) in the four weeks following the index SH episode; post-
cards mailed at one, two, three, four, six, eight, 10 and 12 months following the index SH episode; im-
proved access to primary care via the provision of a voucher that could be used to access one free GP
consultation (duration not reported); development of a risk management strategy; and a cultural as-
sessment focused on identifying patients’ sense of belonging and identification with Māori culture. Ses-

Informed decisions.

sions were delivered by research clinicians (no further information on their expertise or experience was
reported).
Comparator: TAU consisting of referral to multidisciplinary teams for psychiatric/psychological assess-

ment, intervention, or both; referral to crisis teams; or referral to community-based AOD treatment
teams, as required.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from electronic medical records.
Secondary outcome(s): i) repetition of SH as ascertained from self-report; ii) anxiety as measured by the
anxiety subscale of the HADS; ii) belonging as measured by the Sense of Belonging Instrument; iii) de-
pression as measured by the depression subscale of the HADS; iv) cultural identity as measured by the
Cultural Impact Profile (CIP) which is a Maori-specific measure of cultural knowledge and practice; v)
hopelessness as measured by the BHS; vi) quality of life as measured by the EQ-5D and the Social Func-
tioning-36 item (SF-36); vii) service use as measured by self-report supplemented by electronic medical
records; viii) suicide (unclear how ascertained).

Hawton 1981
Methods Participants were individually randomised using sealed, opaque envelopes to either home-based psy-
chotherapy and telephone contact or an alternative form of psychotherapy.
N lost to follow-up: 0/96 (0%) for repetition of SH by the 12-month assessment.
Location: Oxford, UK.
Participants Number of total participants: 96 participants were allocated, 48 were allocated to home-based psy-
chotherapy and telephone contact and 48 were allocated to alternative psychotherapy.
Profile of participants: mean age 25.2 ± 8.2 (range: not reported). The majority (n = 67; 69.8%) were fe-
male, and just under one-third (n = 31; 32.3%).and had a history of SH (i.e. multiple episodes of SH). In-
formation on psychiatric diagnoses not reported.
Source of participants: patients admitted to a general hospital following an episode of self-poisoning.
Inclusion criteria: i) aged over 16 years; ii) suitable for randomisation (e.g. fixed address).
Exclusion criteria: i) in psychiatric care; ii) residing outside the catchment area; iii) requiring treatment
for AOD addiction; iv) referred for inpatient psychiatric care.
Interventions Intervention: mixed domiciliary (home-based) therapy where the frequency of treatment sessions was
flexible (i.e. according to therapists’ ’assessment of needs’). Mean number of sessions was 4.3 (range:
one to eight). Mean duration of sessions was 45.0 ± 7.8 minutes. Open telephone access to the general
hospital service was also available, as required. Therapeutic content included: brief problem-oriented
counselling, problem-solving, and family involvement (as appropriate). Sessions were delivered by ju-
nior psychiatrists, psychiatric nurses, or social workers (no further information on experience was re-
ported).
Comparator: alternative psychotherapy consisting of weekly sessions (mean 4.9, range: one to ten) of
outpatient therapy. Mean duration of sessions was 47.0 ± 8.3 minutes.
Concomitant medication(s): were permitted "...although this was rarely necessary" (Hawton 1981,
p.170). Specific information on the medication(s) prescribed was not reported.

Informed decisions.
Hawton 1981 (Continued)

Length of treatment: up to three months.
Outcomes Primary outcome(s): i) repetition of SH according to hospital records, self-report, and from a GP ques-
tionnaire.
Secondary outcome(s): i) depression as measured using a modification of the Lorr and McNair Mood
Scale; ii) improvement in problems as measured by an idiosyncratic scale; iii) social functioning as
measured using a modification of the Social Adjustment Scale; iv) treatment adherence as measured
by the number that completed treatment; v) suicidal ideation as measured by the BSSI.
Tertiary outcome(s): i) number of GP visits as ascertained from a questionnaire sent to GPs.
Notes Source(s) of funding: “The project was supported by a grant from the Department of Health and Social
Security” (Hawton 1981, p. 177).
Hawton 1987
Methods Participants were individually randomised using a random numbers table to either CBT-based psy-
chotherapy or TAU.
Location: Oxford, UK.
Profile of participants: mean age 29.3 years (SD not reported; range: not reported). Almost two thirds (n
= 53; 66.3%) were female, and just under one-third (n = 25; 31.3%).and had a history of SH (i.e. multiple
episodes of SH). Information on psychiatric diagnoses not reported.
Source of participants: patients admitted to a general hospital following an episode of self-poisoning.
Inclusion criteria: i) aged 16 years or older; ii) registered with a GP; iii) living up to 15 miles away from
hospital; iv) suitable for outpatient counselling; iv) willing to accept aftercare offered.
Exclusion criteria: i) in need of psychiatric care (day-patient or inpatient); ii) currently receiving psychi-
atric care.
Interventions Intervention: outpatient CBT-based psychotherapy consisting of up to eight sessions (54 minutes) of
PST. No specific detail on therapeutic content reported. Sessions were delivered by counsellors from
the clinical team in the general hospital psychiatric service (no further information on experience was
reported).
Comparator: GP management consisting of individual support, marriage counselling, and/or psychi-

atric referral, as required. No information on the number of sessions or their duration reported.
Outcomes Primary outcome(s): i) repetition of SH according to hospital records, self report, collateral informant
report, and/or from a GP questionnaire.
Secondary outcome(s): i) depression as measured by the BDI; ii) improvement in problems as measured
by an idiosyncratic scale; iii) social functioning as measured by the Social Adjustment Scale; iv) sympto-
matology as measured by the GHQ; v) treatment adherence as measured by the number that complet-
ed treatment; vi) treatment attitudes as measured by self-report; vii) suicide (unclear how ascertained).

Informed decisions.
Hawton 1987 (Continued)

Tertiary outcome(s): i) number of GP visits as ascertained from a questionnaire sent to GPs.
Notes Sources of funding: “This study was supported by a grant from the Medical Research Council” (Hawton
1987, p. 760).
Other: As compliance data were not reported for the comparator arm, this outcome had to be excluded
from subsequent analyses.
Husain 2014
Methods Participants were individually randomised using a computer-generated list to either culturally adapted
CBT-based psychotherapy or TAU.
N lost to follow-up: 8/221 (3.6%) for repetition of SH by the six-month assessment.
Location: Karachi, Sindh province, Pakistan.
Profile of participants: mean age 23.1 ± 5.5 (range: 16-64 years). Over two-thirds (n = 53; 66.3%) were fe-
male. A minority (n = 9; 4.1%) had a history of SH (i.e. multiple episodes of SH). Information on psychi-
atric diagnoses not reported.
Source of participants: patients admitted to the medical unit at university hospitals following an
episode of SH.
Inclusion criteria: i) aged 16-64 years; ii) living within the catchment area.
Exclusion criteria: i) referred for inpatient psychiatric treatment; ii) temporarily resident in the catch-
ment area; iii) diagnosed with a psychiatric disorder due to a general medical condition, substance mis-
use, dementia, delirium, substance dependence, schizophrenia, bipolar disorder, or an intellectual dis-
ability according to DSM-IV criteria.
Interventions Intervention: manualised, culturally-adapted CBT-based psychotherapy consisting of six sessions (50
minutes). The first two sessions were held weekly, followed by fortnightly. Therapeutic content includ-
ed: an evaluation of the SH episode, development of crisis management skills, use of problem-solv-
ing and cognitive-behavioural techniques to improve emotion regulation skills, negative thinking, in-
terpersonal relationships, and relapse prevention. Sessions were delivered by qualified, masters-level
psychologists with a minimum of three years post-qualifying clinical experience and who also received
training (duration not reported) in delivering the intervention.
Comparator: TAU. The authors further clarified that “[p]atients are not routinely referred to psychiatric
or psychological services” (Husain 2014, p. 464).
Outcomes Primary outcome(s): i) suicidal ideation as measured by the BSSI.
Secondary outcome(s): i) repetition of SH as ascertained from self-report using the SASII; ii) coping as
measured by the Coping Resource Inventory; iii) depression as measured by the BDI; iv) hopelessness
as measured by the BHS; v) quality of life as measured by the EQ-5D; vi) service use as measured by the
Client Service Receipt Inventory; vii) treatment adherence as measured by the number of sessions at-
tended; viii) days spent in inpatient treatment; ix) attendances at outpatient clinics; x) GP consulta-
tions; xi) consultations with any other doctors; xii) consultations with non-medical religious healers; xi-
ii) consultations with non-medical homeopathic healers.

Informed decisions.
Husain 2014 (Continued)
Notes Source(s) of funding: “This study was jointly funded by the University of Manchester and Pakistan Insti-
tute of Learning and Living” (Husain 2014, p. 469).
Hvid 2011
Methods Participants were individually randomised, stratified by sex, history of SH, history of previous psychi-
atric treatment, and use of alcohol during the index SH to either case management or TAU.
Location: Amager, Denmark.
Participants Number of total participants: 133 participants were allocated, 69 were allocated to assertive outreach
and 64 were allocated to TAU.
Profile of participants: mean age 37.5 ± 18.2 (range: not reported). Almost three-quarters (n = 95; 71.4%)
were female. Over one-third (n = 51; 38.3%) had a history of SH (i.e. multiple episodes of SH) and a his-
tory of previous psychiatric treatment (n = 49; 36.8%); however, information on psychiatric diagnoses
was not reported.
Source of participants: patients admitted to an emergency or clinical department following an episode

of SH.
Inclusion criteria: i) admitted to an emergency department or clinical department following an episode

of SH.
Exclusion criteria: i) less than 12 years old; ii) diagnosed with any major psychiatric illness, including:
schizophrenia, other psychoses, bipolar disorder, major depression, psychotic depression, mental re-
tardation, and severe dementia; iii) insufficient language ability.
Interventions Intervention: case management consisting of assertive outreach delivered according to the Baerum
model, involving: assertive outreach via home visits (mean number of home visits was eight, range
three to 22), telephone calls, email messages, and text messages (range five to 36), sessions (number
and duration not reported) of solution-focused PST, adherence therapy, and treatment continuity as
participants were contacted by the same psychiatric nurse (as far as practical) throughout the course of
treatment. Sessions were delivered by consultant-level psychiatrists or psychiatric nurses (no further
information on experience was reported).
Comparator: TAU involving encouraging participants to contact their GP who could, where required, re-
fer the participant on to further psychiatric or psychological treatment.
Length of treatment: maximum period of six months.
Outcomes Primary outcome(s): i) repetition of SH according to clinical records; ii) suicide according to Coroner's
records.
Notes Source(s) of funding: “The trial has been funded by a grant from the Danish Ministry of Social Affairs, the
Lundbeck Foundation and the Health Insurance Foundation” (Hvid 2011, p. 297).
Kapur 2013

Informed decisions.
Kapur 2013 (Continued)
Methods Participants were individually randomised using web-based software to a remote contact intervention
(postcards) or TAU.
N lost to follow-up: 1/66 (1.5%) at post-intervention.
Location: Manchester, UK.
Participants Number of total participants: 66 participants were allocated, 33 were allocated to the remote contact
intervention (postcards) and 33 were allocated to TAU.
Profile of participants: not reported, although the authors noted “[i]ntervention and usual treatment
groups were similar in terms of age, gender” (Kapur 2013, p. 73). Just over half (n = 39; 59.1%) had a his-
tory of SH (i.e. multiple episodes of SH prior to trial entry).
Source of participants: patients presenting to ED following an episode of SH.
Inclusion criteria: i) i) aged 18 or older; ii) resident in the catchment area; iii) presenting to ED following
an episode of SH.
Exclusion criteria: i) referred for admission to a psychiatric unit; ii) without a telephone; iii) admitted to
a general hospital for a period of greater than seven days; iv) living outside of the catchment area; v)
deterioration in psychosis symptoms; vi) denies SH; vii) declined to participate.
Interventions Intervention: remote contact intervention consisting of a series of postcards mailed at one, two, four,
six, eight, and 12 months post-discharge, an information leaflet listing both local and national sources
of support, and two semi-structured telephone calls to facilitate referral to appropriate specialist treat-
ment, as required, in addition to TAU. Postcards encouraged participants to make contact with the ser-
vice, if required. Sessions were delivered by clinical researchers (no further information on expertise or
experience was reported).
Comparator: TAU consisting of referral to mental health services, social services, or voluntary sector
services, as required.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from hospital records; ii) frequency of SH as as-
certained from hospital records.
Secondary outcome(s): i) number of ED attendances; ii) number of days on a medical inpatient ward; iii)
number of face-to-face contacts with mental health services; iv) number of admissions to psychiatric
inpatient services; v) suicide (unclear how ascertained).
Notes Source(s) of funding: “commissioned by the National Institute for Health Research (NIHR) under its Pro-
gram Grants for Applied Research scheme (RP-PG-0606-1247)” (Kapur 2013, p. 74)
Conflict(s) of interest: “N.K. chaired the National Institute for Health and Clinical Excellence (NICE)
guideline development group and evidence for the longer-term management of self-harm. N.K., D.G.,
K.H. are members of the National Suicide Prevention Strategy Advisory Group” (Kapur 2013, p. 73).
Kawanishi 2014
Methods Participants were individually randomised using web-based software using minimisation stratified by
site, age, and history of SH to either assertive outreach and case management or EUC.
Location: various sites, Japan.

Informed decisions.
Kawanishi 2014 (Continued)
Participants Number of total participants: 914 participants were allocated, 460 were allocated to case management
and assertive outreach and 454 were allocated to EUC.
female, and just under half (n = 450; 49.2%) had a history of SH (i.e. multiple episodes of SH). Informa-
tion on psychiatric diagnoses reported in a separate publication (Furuno 2018); under half (n = 426;
46.6%) were diagnosed with any mood disorder, adjustment disorder (n = 191; 20.9%), psychosis (n =
179; 19.6%), SUD (n = 45; 4.9%), and other disorders (unspecified) (n = 73; 8.0%).
Source of participants: patients admitted to EDs following a suicide attempt.
Inclusion criteria: i) aged 20 years or older; ii) admitted to EDs following a suicide attempt; iii) ≥ 2 previ-
ous suicide attempts rated as having definite suicidal intent as determined by scores on the Suicide In-
tent Scale; iv) diagnosed with any Axis I psychiatric disorder according to DSM-IV-TR criteria; v) able to
understand the trial procedure; vi) able to provide informed consent; vii) able to attend a face-to-face
interview; viii) able attend a psychoeducation session during the hospital admission.
Exclusion criteria: i) diagnosed with any psychiatric disorder which did not meet DSM-IV-TR criteria.
Interventions Intervention: assertive outreach and case management involving contact with patients at week one and
one, two, three, six, 12, and 18 months after the index suicide attempt with a view to collecting infor-
mation about the participant’s treatment status and any problems that could interfere with treatment
adherence. Therapeutic content included: providing encouragement to remain adherent with treat-
ment, coordination and referral to appointments with psychiatrists and any other primary care physi-
cians, outreach for those who had dropped out of treatment, referral to social services and other sup-
port organisations, as needed, psychoeducation, and access to a dedicated website designed to pro-
vide participants with information and resources. Sessions were delivered by psychiatrists, clinical psy-
chologists, nurses, and social workers (no further information on experience was reported).
Comparator: EUC. No further details on treatment content provided.
Outcomes Primary outcome(s): i) time to SH repetition (unclear how ascertained); ii) repetition of SH (unclear how
ascertained); iii) suicide as ascertained from a mortality register; iv) all-cause morality as ascertained
from a mortality register.
Secondary outcome(s): i) hopelessness as measured by the BHS; ii) quality of life as measured by the
SF-36; iii) service contacts as ascertained from records; iv) physical functioning (unclear how ascer-
tained).
Notes Source(s) of funding: “This study was funded by the Ministry of Health, Labour, and Welfare of
Japan” (Kawanishi 2014, p. 200).
Other: The authors stated that for "[o]ther protocol-specified secondary outcomes...We plan to publish
results for all these outcomes in a separate report" (Kawanishi 2014, p. 196).
Liberman 1981
Methods Participants were individually randomised (method not reported) to either a mixed intervention or al-
ternative psychotherapy.
N lost to follow-up: 0/24 (0%) for repetition of SH at post-intervention (including up to the 24-month as-
sessment).
Location: Los Angeles, CA, USA.

Informed decisions.
Liberman 1981 (Continued)
Participants Number of total participants: 24 participants were allocated, 12 were allocated to a mixed intervention
and 12 were allocated to alternative psychotherapy.
Profile of participants: mean age 29.7 ± 8.8 years (range: 18-47 years). Two thirds (n = 16; 66.6%) were fe-
male. All (n = 24; 100%) had a history of SH (i.e. multiple episodes of SH). Whilst all (n = 24; 100%) had
previously received psychiatric treatment, information on psychiatric diagnoses was not reported.
Source of participants: patients referred by psychiatric emergency services or hospital A&E following an
episode of SH.
Inclusion criteria: i) ≥ 1 suicide attempt preceding trial entry.
Exclusion criteria: i) diagnosed with psychosis; ii) addicted to drugs and alcohol; ii) diagnosed with or-
ganic brain syndrome.
Interventions Intervention: inpatient treatment consisting of daily sessions (duration not reported). Therapeutic con-
tent included: behaviour therapy, social skills training, anxiety management, and family therapy. A
therapeutic milieu with a token economy was also established. Aftercare at a community mental health
centre or with a private therapist was also used, as required. Sessions were delivered by psychologists
assisted by bachelors-level technicians (no further information on experience was reported).
Comparator: alternative psychotherapy (inpatient treatment involving insight-oriented therapy) con-

sisting of daily sessions (duration not reported). Therapeutic content included: individual therapy,
group therapy and psychodrama, and family therapy. A therapeutic milieu with a token economy was
also established. Aftercare at a community mental health centre or with a private therapist was also
used, as required.
Length of treatment: 10 days.
Outcomes Primary outcome(s): i) repetition of SH ascertained by self-report; ii) depression as measured by the
Zung Self-rating Depression Scale, the BDI, and the depression subscale of the Minnesota Multiphasic
Personality Inventory (MMPI); iii) suicidal ideation as ascertained by self-report.
Secondary outcome(s): i) assertiveness as measured by the Assertiveness Questionnaire; ii) fear as mea-
sured by the Fear Survey Schedule; iii) reinforcement as measured by the Reinforcement Survey Sched-
ule.
Notes Source(s) of funding: “The project was made possible by grant MH 22804 from the Clinical Research
Branch of the National Institute of Mental Health to Michael Serber, MD, and R.P.L., the co-principal in-
vestigators” (Liberman 1981, p. 1130).
Conflict(s) of interests: no information on interests reported.
Lin 2020
Methods Participants were individually randomised using a computerised blocking procedure to either CBT-
based psychotherapy and standard case management or TAU.
N lost to follow-up: 3/150 (2.0%) for repetition of SH by the six- and 12-month assessment.
Location: Taipei and New Taipei City, Taiwan.
Participants Number of total participants: 147 participants were randomised, 75 were allocated to brief CBT-based
psychotherapy and standard case management, and 75 were allocated to TAU.
Profile of participants: mean age 33.0 ± NR years (range: 18-81 years). The majority (n = 106; 72.1%) were
female. Over half had a history of SH (i.e. multiple episodes of SH) (n = 88; 59.9%). Most were diagnosed

Informed decisions.
Lin 2020 (Continued)

with an alcohol use disorder (n = 52; 38.2%), followed by major depression (n = 54; 36.7%), and bipolar
disorder (n = 20; 14.0%).
Source of participants: patients presenting to EDs following a suicide attempt.
Inclusion criteria: i) 18 years of age or older; ii) reporting current suicidal ideation; iii) sufficient language
ability; iv) able to provide informed consent; v) able to be contacted via mail or telephone.
Exclusion criteria: i) medically or cognitively incapable of participating in the study procedure; ii) insuffi-
cient language ability; iii) receiving other research or psychotherapy.
Interventions Intervention: brief CBT-based psychotherapy in addition to standard case management, consisting
of up to six sessions (in person or via telephone) at weeks' one, two, four, seven, 11, and 15 post-dis-
charge. Session frequency could be increased to up to one per week, depending on risk. Mean dura-
tion of face-to-face sessions was 45.6 ± 14.9 minutes (range: 15-70 minutes), whilst the mean duration
of telephone sessions was 26.2 ± 10.5 minutes (range 13-55 minutes). Therapeutic content included: a
suicide risk assessment, safety planning, chain analysis, problem-solving skills training, distress toler-
ance, and seeking resources. Sessions were delivered by case managers (no further information on ex-
pertise or experience was reported).
Comparator: TAU consisting of admission to a general medical/surgical ward or a psychiatric ward (as
needed), followed by referral to a specialist suicide prevention centre for ongoing outpatient psychi-
atric treatment (as required). Participants were not routinely referred for psychotherapy from this cen-
tre.
Length of treatment: four months.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report supplemented by information

from medical records.
Secondary outcome(s): i) psychiatric service use, as measured by the number of service contacts; ii) de-
pression, as measured by the HAMD-24; iii) hopelessness, as measured by the BHS; iv) suicidal ideation,
as measured by the BSSI.
Notes Source(s) of funding: "This study was funded by the National Science Council of the Republic of China,
Taiwan" (Lin 2020, pp. 693-4).
Linehan 1991
Methods Participants were individually randomised using a computerised procedure to either manualised DBT
or TAU.
N lost to follow-up: 19/63 (30.2%) for repetition of SH by the post-intervention assessment. Additional-
ly, data for 24/63 (38.1%) participants were deliberately not included in the 24-month follow-up assess-
ment.
Participants Number of total participants: 63 participants were randomised, 31 were allocated to DBT and 31 were
allocated to TAU.
Profile of participants: mean age not reported (range: 18-45 years). All (n = 63; 100%) were female and
had a history of SH (i.e. multiple episodes of SH).
Source of participants: referred patients with ≥ 1 episode of SH in the 8 weeks preceding trial entry.

Informed decisions.
Linehan 1991 (Continued)

Inclusion criteria: i) female; ii) aged 18-45 years; iii) diagnosed with BPD; iv) ≥ 2 suicide attempts in the
five years preceding trial entry with ≥ 1 in the eight weeks preceding trial entry; v) agree to trial condi-
tions.
Interventions Intervention: manualised DBT consisting of weekly (60 minutes) sessions of individual psychotherapy,
and weekly (2.5 hours) sessions of group skills training, as well as telephone consultation, as required
(within each therapists’ limitations), and weekly therapist team meetings. Therapeutic content includ-
ed: DBT developed specifically for the treatment of suicidal patients with BPD, which targeted increas-
ing behavioural capabilities and motivation for treatment whilst also reinforcing functional behaviour.
Sessions were delivered by psychiatrists, psychologists, or clinical psychology graduates (no further in-
formation on experience was reported).
Comparator: TAU consisting of referral to alternative therapy.
Outcomes Primary outcome(s): i) repetition of SH according to self-report using the Parasuicide History Interview.
Secondary outcome(s): i) coping as measured by the Survival and Coping Scale; ii) depression as mea-
sured by the BDI; iii) hopelessness as measured by the BHS and the Reasons for Living Inventory; iv)
service usage as ascertained from self-report using the Treatment History Interview; v) suicidal ideation
as measured by the BSSI; vi) suicide (unclear how ascertained).
Notes Source(s) of funding: ”This research was supported by grant MH34486 from the National Institute of
Mental Health, Bethesda, Md (Dr Linehan)" (Linehan 1991, p.1064).
Conflict(s) of interests: Although no information on conflicts of interests were reported, Dr. Linehan has
developed dialectical behaviour therapy.
Other: Half (50%) of the self-reported episodes of SH were checked against medical records, therapist
records, and observer/nurse/physician ratings.
Linehan 2006
Methods Participants were individually randomised using a computerised adaptive minimisation procedure to
either manualised DBT or alternative psychotherapy (treatment by experts).
Participants Number of total participants: 101 participants were randomised, 52 were allocated to DBT and 49 were
allocated to alternative psychotherapy (treatment by experts).
Profile of participants: mean age 29.3 ± 7.5 years (range: 18-45 years). All (n = 101; 100%) were female
and were diagnosed with BPD. Almost all (n = 97; 96.0%) were also diagnosed with MDD, followed by
SUD (n = 88; 87.1%), any anxiety disorder (n = 54; 55.4%), any eating disorder (n = 40; 39.6%), avoidant
PD (n = 21; 20.8%), and ASPD (n = 11; 10.9%).
Source of participants: clinical referrals and individuals attending inpatient units, emergency rooms
and outpatient clinics.
Inclusion criteria: i) 18-45 years; ii) female; iii) meets criteria for BPD; iv) ≥ 2 suicide attempts or episodes
of SH in the five years preceding trial entry, with ≥ 1 in the eight weeks preceding trial entry.
Exclusion criteria: i) lifetime diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, psy-
chotic disorder not otherwise specified, or mental retardation; ii) seizure disorder requiring medica-

Informed decisions.

tion; iii) legally mandated to treatment; iv) requiring primary treatment for another debilitating condi-
tion.
Interventions Intervention: manualised DBT consisting of weekly (60 minutes) sessions of individual psychotherapy,
and weekly (2.5 hours) sessions of group skills training, as well as telephone consultation, as required
(within each therapists’ limitations), and weekly therapist team meetings. Therapeutic content includ-
ed: CBT developed specifically for the treatment of for suicidal patients with BPD which targeted in-
creasing behavioural capabilities and motivation for treatment whilst also reinforcing functional be-
haviour. Sessions were delivered by trained doctoral-level therapists (one-quarter had over 10 years ex-
perience working with suicidal persons).
Comparator: TAU consisting of community treatment by experts specifically designed for the trial to
control for factors previously uncontrolled in DBT trials. Whilst similar to TAU, as therapists were free
to decide on type and dose of therapy they believed was most suited to the patient (minimum of one
scheduled individual session per week; duration not reported), the characteristics of therapists were
controlled via selection of therapists and supervisory arrangements.
Outcomes Primary outcome(s): i) repetition of SH according to self-report using the SASII.
Secondary outcome(s): i) medical severity of SH according to self-report using the SASII; iii) hopeless-
ness as measured by the Reasons for Living Inventory; iv) service usage as ascertained from self-report.
Notes Source(s) of funding: “This study was supported by grants MH34486 and MH01593 from the National In-
stitute of Mental Health” (Linehan 2006; p. 765).
Conflict(s) of interests: although no information on conflicts of interests were reported, Dr Linehan de-
veloped dialectical behaviour therapy.
Linehan 2015
Methods Participants were individually randomised using a computerised adaptive procedure stratified by
age, number of previous suicide attempts, number of previous episodes of NSSI, psychiatric hospital-
isations (past year), and depression severity to either DBT plus group-based skills training (Linehan
2015a), individual-based DBT (Linehan 2015b), or standard manualised DBT.
Participants Number of total participants: 99 participants were randomised, 33 were allocated to DBT plus group-
based skills therapy, 33 were allocated to individual-based DBT, and 33 were allocated to standard DBT.
Profile of participants: mean age 30.3 ± 8.9 years (range: 18-60 years). All (n = 99; 100%) were female.
The majority were diagnosed with any anxiety disorder (n = 81; 96.4%), followed by MDD (n = 70;
70.7%), any SUD (n = 37; 37.4%), and any eating disorder (n = 15; 15.1%). Almost three-quarters (n = 73;
73.7%) were also diagnosed with a personality disorder; commonly avoidant personality disorder (n =
26; 26.3%).
Source of participants: patients currently receiving treatment from outpatient mental health services.
Inclusion criteria: i) 18 to 60 years of age; ii) diagnosed with BPD according to DSM-IV criteria; iii) ≥ 2
episodes of suicide attempt/NSSI in the five years preceding trial entry with ≥ 1 of these episodes in the
year preceding trial entry and ≥ 1 of these episodes in the eight weeks preceding trial entry.

Informed decisions.

Exclusion criteria: i) IQ score < 70 on the Peabody Picture Vocabulary Test-Revised; ii) diagnosed with
psychosis or bipolar disorder; iii) diagnosed with a seizure disorder requiring medication; iv) requiring
treatment for another life-threatening condition (e.g. severe anorexia nervosa).
Interventions See Linehan 2015a and Linehan 2015b for a detailed description.
Outcomes Primary outcome(s): i) repetition of SH according to self-report using the SASII; ii) frequency of SH ac-
cording to self-report using the SASII.
Secondary outcome(s): i) hopelessness as measured using the Reasons for Living Inventory (reverse
scored); ii) depression as measured using the HRSD; iii) anxiety as measured using the Hamilton Rating
Scale for Anxiety.
Notes Source(s) of funding: "This study was supported by grant R01MH034486 from the National Institute of
Mental Health for the design and conduct of the study and for collection, management, analysis, and
interpretation of the data" (Linehan 2015, p.8).
Conflict(s) of interest: "Dr Linehan receives royalties from Guilford Press for books she has written on Di-
alectical Behavior Therapy (DBT) and from Behavioral Tech, LLC, for DBT training materials she has de-
veloped; she owns Behavioral Tech Research, Inc, a company that develops online learning and clinical
applications that include products for DBT. Drs Linehan, Korslund, Harned, Neacsiu, and Comtois are
compensated for providing DBT training and consultation. No other disclosures were reported" (Line-
han 2015, p.8).
Linehan 2015a
Methods See Linehan 2015 for a detailed description.
Participants See Linehan 2015 for a detailed description.
Interventions Intervention (DBT plus group skills training): comprising manualised case management (duration not
reported), weekly group skills training (2.5 hours), DBT consultation team meeting (1 hour), and tele-
phone coaching, as needed. Participants did not receive individual therapy. Sessions were delivered by
therapists (one-third were doctoral-level therapists), the majority of whom had over 10 years clinical
experience working with suicidal persons and who received training (duration not reported) in deliver-
ing the intervention and ongoing supervision.
Comparator: comprising weekly sessions of individual therapy (1 hour), group skills training (2.5 hours),
DBT consultation team meeting (1 hour), and telephone coaching, as needed.
Concomitant medications: were permitted. The average number of psychotropic medications pre-
scribed at baseline was 3.1 ± 2.7.
Outcomes See Linehan 2015 for a detailed description.
Notes See Linehan 2015 for a detailed description.
Linehan 2015b

Informed decisions.
Linehan 2015b (Continued)
Methods See Linehan 2015 for a detailed description.
Participants See Linehan 2015 for a detailed description.
Interventions Intervention (individual-based DBT): comprising weekly sessions of individual therapy (1 hour), DBT
consultation team meeting (1 hour), and telephone coaching, as needed. Participants did not receive
group skills training. Sessions were delivered by therapists (93% were doctoral-level therapists), the
majority of whom had over 10 years clinical experience working with suicidal persons and who received
training (duration not reported) in delivering the intervention and ongoing supervision.
Comparator: comprising weekly sessions of individual therapy (1 hour), group skills training (2.5 hours),
DBT consultation team meeting (1 hour), and telephone coaching, as needed.
Concomitant medications: were permitted. The average number of psychotropic medications pre-
scribed at baseline was 3.1 ± 2.7.
Outcomes See Linehan 2015 for a detailed description.
Notes See Linehan 2015 for a detailed description.
Marasinghe 2012
Methods Participants were individually randomised using an unknown method to either a remote contact inter-
vention (brief psychotherapy delivered by mobile phone) or waiting list.
Location: Colombo, Sri Lanka.
Participants Number of total participants: 68 participants were randomised; 34 were allocated to the mobile phone
based psychotherapy, and 34 were allocated to waiting list.
Profile of participants: mean age 31.0 ± 14.8 years (range: 15-74 years). Half (n = 34; 50.0%) were female.
No information on psychiatric diagnoses reported.
Inclusion criteria: i) aged 15-74 years; ii) admitted to hospital following an episode of SH; iii) episode of
SH was associated with significant suicidal intent as reported either at the intake interview or accord-
ing to scores on BSS; iv) considered likely to be discharged from hospital within 2 days or able to be re-
approached if admitted for longer than 2 days; v) able to provide informed consent.
Exclusion criteria: i) currently receiving ongoing psychiatric treatment; ii) diagnosed with psychosis; iii)
diagnosed with dementia.
Interventions Intervention: brief mobile intervention consisting of an assessment of mental health, meditation, PST,
interventions to increase social support, interventions to address alcohol or other substance misuse
problems, a series of 10 telephone calls to reaffirm techniques learnt during treatment, the ability to
access telephone messages to reaffirm techniques learnt during treatment, and a series of up to 26 text
messages to encourage the participant to practice meditation techniques, problem-solving skills, to
seek social support, to avoid alcohol and other drugs, and to use the telephone helpline to get individ-
ual support in times of crisis. No information on who delivered the intervention, their expertise, or their
experience was reported.
Comparator: waiting list.

Informed decisions.
Marasinghe 2012 (Continued)

Length of treatment: up to 26 weeks.
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) AOD use as measured by the AU-
DIT and the Drug Check Problem List; iii) depression as measured by the BDI; iv) social support as mea-
sured by the Medical Outcomes Study; v) suicidal ideation as measured by the BSSI; v) suicide (unclear
how ascertained).
Notes Source(s) of funding: “We are grateful for funding from the Improving Relevance and Quality of Under-
graduate Education (IRQUE) project of the University of Jeyewardenepura, Sri Lanka” (Marasinghe
2012, p. 155).
Conflict(s) of author interests: no information on author interests reported.
McAuliffe 2014
Methods Participants were individually randomised using a computer-generated sequence of numbers stratified
by sex, SH repeater status, and trial site to either manualised, group-based CBT-based psychotherapy
or TAU.
Location: Cork and Limerick, Republic of Ireland.
Participants Number of total participants: 433 participants were randomised; 222 were allocated to the group-based
CBT-based psychotherapy, and 211 were allocated to TAU.
Profile of participants: mean age 33.5 ± 11.8 years (range: 18-64 years). Almost two-thirds (n = 279;
64.4%) were female. Just under one-third (n = 127; 29.3%) had a history of SH (i.e. multiple episodes of
SH). No information on psychiatric diagnoses reported.
Source of participants: patients presenting to the ED following an episode of SH, or patients engaging in
SH in acute psychiatric facilities even if this did not necessitate admission to the ED.
Inclusion criteria: i) aged 18-64 years; ii) engaged in SH in the three days preceding trial entry.
Exclusion criteria: i) diagnosed with psychosis, intellectual disability, sensory disability, or an organic
cognitive impairment; ii) currently substance dependent according to scores on the Short Alcohol De-
pendent Data questionnaire; iii) imprisoned; iv) no fixed address.
Interventions Intervention: manualised problem-solving skills training consisting of six (two hour) sessions facilitat-
ed by a trained therapist and a co-therapist. Therapeutic content involved problem-solving skills train-
ing. Sessions were delivered by therapists (expertise and experience not reported) who received train-
ing (duration not reported) in delivering the intervention.
Comparator: TAU consisting of an assessment by mental health professional staff and by crisis staff, and
referral to acute mental health or community-based services, psychotherapy, and pharmacotherapy,
as necessary.
Length of treatment: six weeks.
Outcomes Primary outcome(s): i) repetition of SH (as ascertained from self-report for the 6-week and 6-month fol-
low-up assessment and from hospital records for the 12-month assessment); ii) suicide as ascertained
from hospital records.
Secondary outcome(s): i) anxiety as measured by the Beck Anxiety Inventory (BAI); ii) depression as
measured by the BDI; iii) hopelessness as measured by the BHS; iv) impulsivity as measured by BIS;
v) problem-solving skills as measured by the Means-Ends Problem-Solving Procedure (MEPS) and the
Self-Rating Problem-Solving Scale; vi) self-efficacy as measured by the Generalised Self-efficacy Scale;

Informed decisions.
McAuliffe 2014 (Continued)

vii) social functioning as measured by the Social Life Scale; vii) suicidal ideation as measured by the
BSSI.
Notes Source(s) of funding: “This work was supported by funding from the Health Service Executive (HSE)
South, HSE Mid-West, the HSE National Office for Suicide Prevention, the Health Research Board and
Pobal-Dormant Accounts Fund in Ireland” (McAuliffe 2014, p. 389).
McLeavey 1994
Methods Participants were individually randomised using an open numbers table to either interpersonal prob-
lem-solving skills training or alternative psychotherapy (brief PST).
Location: Cork, Republic of Ireland.
Participants Number of total participants: 39 participants were randomised, 19 were allocated to interpersonal
problem-solving skills, and 20 were allocated to alternative psychotherapy.
Profile of participants: mean age 23.9 ± 7.2 years (range: 15-45 years). Just under three-quarters (n = 29;
74.3%) were female. Over one-third (n = 14; 35.9%) had a history of SH (i.e. multiple episodes of SH).
Almost one-quarter (n = 9; 23.1%) were diagnosed with dysthymia, followed by dependent PD (n = 6;
15.4%), and AUD (n = 5; 12.8%).
Source of participants: patients admitted to an A&E department following an episode of self-poisoning.
Inclusion criteria: i) aged 15-45 years; ii) score ≥ 80 on the Mill Hill Vocabulary Scale.
Exclusion criteria: i) history of psychosis, mental retardation, or organic cognitive impairment; ii) re-
ferred for psychiatric treatment (day care or inpatient).
Interventions Intervention: manualised interpersonal problem-solving skills training (number and duration of ses-
sions not reported). Therapeutic content involved instruction, active discussion, reflective listening,
modelling, coping strategy, role playing, sentence completion, and prompting. Sessions were delivered
by psychiatry registrars and clinical psychologists (no further information on experience was reported).
Comparator: alternative psychotherapy (brief problem-solving therapy) (number and duration of ses-
sions not reported). Therapeutic content involved focusing on patients’ current problems and preven-
tion by helping patients gain insight into problems. No specific skills training was provided, however.
Length of treatment: five weeks.
Outcomes Primary outcome(s): i) repetition of SH ascertained from hospital records and a GP questionnaire.
Secondary outcome(s): i) hopelessness as measured by the BHS; ii) problem-solving as measured by the
MEPS, the Optional Thinking Test, the Awareness of Consequences Test, the Self-Rating Problem-Solv-
ing Scale, and the Problems Questionnaire; iii) self-concept as measured by the Self-Perception Scale;
iv) suicide (unclear how ascertained).
Notes Source(s) of funding: no information on funding sources reported.

Conflict(s) of interest: Although no conflicts of interest were reported, Dr McLeavey was the developer of
interpersonal problem-solving skills training.

Informed decisions.
McMain 2009
Methods Participants were individually randomised using a pre-generated blocking procedure to either interper-
sonal DBT or TAU.
Location: Toronto, ON, Canada.
Participants Number of total participants: 180 participants were randomised, 90 were allocated to DBT, and 90 were
allocated to TAU.
female. All (n = 180; 100%) had a history of SH (i.e. multiple episodes of SH), and were diagnosed with
BPD. Three-quarters (n = 135; 75.0%) were diagnosed with any anxiety disorder, just under half (n = 88;
48.9%) were diagnosed with MDD, followed by PTSD (n = 71; 37.4%), panic disorder (n = 39; 21.7%), and
SUD (n = 17; 9.4%).
Source of participants: patients attending a specialised Centre for Addiction and Mental Health, hospital
or both.
Inclusion criteria: i) aged 18-60 years; ii) met DSM-IV criteria for BPD; iii) ≥ 2 episodes of suicide attempts
and/or NSSI in the past five years with ≥ 1 in the three months preceding trial entry.
Exclusion criteria: i) met DSM-IV criteria for a psychotic disorder, bipolar I disorder, delirium, dementia,
or mental retardation; ii) diagnosed with substance dependence in the 30 days preceding trial entry; iii)
did not live within communing distance; iv) diagnosed with a serious medical condition likely to require
hospitalisation within one year (e.g. cancer); v) planning to move out of the catchment area within two
years.
Interventions Intervention: manualised DBT consisting of weekly (60 minutes) sessions of individual therapy, group-
based skills training (two hours), and telephone-based coaching (2 hours). Number of sessions not re-
ported. Therapeutic content involved: psychoeducation, validation and empathy, mindfulness, expo-
sure, contingency management, and behavioural analysis with an explicit focus on SH and suicidal be-
haviour. Additionally, therapists attended weekly therapist team meetings. Sessions were delivered by
board-certified psychiatrists and doctoral-level clinicians (no further information on experience was re-
ported).
Comparator: TAU (general psychiatric management) consisting of weekly (60 minutes) sessions of indi-
vidual therapy focused on improving medication management through the use of a structured drug al-
gorithm. Participants also received psychoeducation, providing validation and empathy within a ’here
and now’ focus. Additionally, therapists attended weekly therapist team meetings. Number of sessions
not reported.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report using the SASII; ii) frequency of
SH as ascertained from self-report using the SASII; iii) severity of SH as ascertained from self-report us-
ing the SASII.
Secondary outcome(s): i) anger as measured by the STAXI; ii) BPD symptomatology as measured by the
Zanarini Rating Scale for Borderline Personality Disorder; iii) depression as measured by the BDI; iv)
general symptomatology as measured by the SCL-90; v) interpersonal problems as measured by the In-
ventory of Interpersonal Problems, 64-item version; vi) quality of life as measured by the EQ-5D; vii) ser-
vice use as ascertained from self-report; viii) reasons for dropout as measured by the Reasons for Ear-
ly Termination From Treatment Questionnaire; ix) treatment adherence as measured by the number of
sessions attended; x) suicide (unclear how ascertained).
Notes Source(s) of funding: “Supported by grant 200204MCT-101123 from the Canadian Institutes for Health
Research” (McMain 2009, p. 1373)

Informed decisions.
McMain 2009 (Continued)

Conflict(s) of interest: “Dr. Links has received an unrestricted educational grant from Eli Lilly Canada Inc.
All other authors report no competing interests” (McMain 2009, p. 1373).
Other: data on hospital admissions for self-harm obtained from self-report following clinician interview.
McMain 2017
Methods Participants were individually randomised via a blocking procedure either to 20 weeks of a DBT skills
training program or active waiting list.
Location: Toronto, Canada.
Participants Number of total participants: 84 participants were randomised, 42 were allocated DBT plus group skills
therapy and 42 were allocated to waiting-list control.
Profile of participants: mean age 29.7 ± 8.6 years (range: 18-60 years). Over three-quarters (n = 66;
78.6%) were female. The majority (n = 51; 60.7%) were diagnosed with any anxiety disorder, followed
by SUD (n = 47 56.0%), MDD (n = 43; 51.2%), PTSD (n = 19; 22.6%), any eating disorder (n = 13; 15.5%),
and panic disorder (n = 12; 14.3%).
Source of participants: patients currently receiving treatment from outpatient mental health services.
Inclusion criteria: i) 18-60 years of age; ii) diagnosed with BPD according to DSM-IV criteria; iii) ≥ 2
episodes of SH in the five years preceding trial entry with ≥ 1 episode in the 10 weeks preceding trial en-
try; iv) sufficient language ability.
Exclusion criteria: i) diagnosed with psychosis, bipolar disorder, or dementia according to DSM-IV crite-
ria; ii) diagnosed with an organic disorder or intellectual disability; iii) received DBT within the year pre-
ceding trial entry.
Interventions Intervention: manualised DBT plus group skills therapy consisting of a single (90 minute) individual ori-
entation session followed by weekly sessions (two hours) of group skills training comprising mindful-
ness, emotion regulation, distress tolerance, interpersonal effectiveness, and dialectics. Participants
were also provided with the numbers for 24-hour crisis lines.
Comparator: waiting-list control.
Concomitant medications: 71 participants (84.5%) were prescribed psychotropic medications (mean 1.8
± 1.4 medications per participant).
Outcomes Primary outcome(s): i) frequency of SH as ascertained from the clinician-report using the Lifetime Sui-
cide Attempt Self-Injury Interview (LSASI) together with self-report using the Deliberate Self-Harm In-
ventory (DSHI).
Secondary outcome(s): i) healthcare utilisation as measured using the Treatment History Interview-2
(THI-2); ii) number of ED visits as measured using the THI-2; iii) number of psychiatric hospital admis-
sions as measured using the THI-2; iv) use of medications as measured using the THI-2; v) borderline
personality symptoms as measured using the Borderline Symptoms List-23; vi) anger as measured by
the State-Trait Anger Expression Inventory; vii) general symptoms as measured by the Symptom Check-
list-90-Revised; viii) impulsiveness as measured by the Barrett Impulsiveness Scale-11; ix) depression
as measured by the BDI; x) social functioning as measured by the Social Adjustment Scale-Self-Report;
xi) emotion regulation as measured by the Difficulties in Emotion Regulation Scale; xii) distress as mea-
sured by the Distress Tolerance Scale; xiii) mindfulness skills as measured by the Kentucky Inventory of

Informed decisions.

Mindfulness Scale; xiv) treatment adherence as measured by the Reasons for Early Termination from
Treatment Questionnaire (for dropouts).
Notes Source(s) of funding: "The study was funded by the Ontario Mental Health Foundation (McMain 2017, p.
147).
Conflict(s) of interest: "The authors report no conflict of interests in relationship to this study" (McMain
2017, p. 147).
Morgan 1993
Methods Participants were individually randomised using sealed envelopes to a remote contact intervention
(emergency card) or TAU.
Location: Bristol, UK.
Participants Number of total participants: 212 participants were randomised, 101 were allocated to the remote con-
tact intervention (emergency card), and 111 were allocated to TAU.
Profile of participants: mean age 30.1 years (SD: not reported; range: not reported). Proportion female
not reported. All (n = 212; 100%) had engaged in SH for the first time. One-quarter (n = 53; 25.0%) were
diagnosed with a depressive disorder.
Source of participants: patients admitted to hospital following first episode of SH.
Inclusion criteria: i) no previous episode of SH; ii) resident within the catchment area.
Interventions Intervention: remote contact intervention (emergency card) in addition to TAU. The green card outlined
that a doctor was available by telephone and provided their contact information and enabled partici-
pants to on-demand admission to hospital. Sessions were delivered by duty doctors (no further infor-
mation on expertise or experience was reported).
Comparator: TAU consisting of referral to the primary healthcare team, and psychiatric or inpatient ad-
missions, if required. No information on the number or duration of sessions was reported.
Outcomes Primary outcome(s): i) repetition of SH ascertained from hospital, psychiatric, and GP records.
Secondary outcome(s): i) use of the emergency card ascertained from hospital, psychiatric, and GP
records; ii) admission to psychiatric hospital ascertained from records ascertained from hospital, psy-
chiatric, and GP records; iii) service use ascertained from hospital, psychiatric, and GP records.
Notes Source(s) of funding: no sources of funding were reported.

Conflict(s) of interest: no conflicts of interest were reported.
Morthorst 2012

Informed decisions.
Morthorst 2012 (Continued)
Methods Participants were individually randomised using a computer-based software stratified by history of sui-
cide attempts, history of psychiatric treatment or hospitalisation, and alcohol consumption at the in-
dex attempt to either case management or EUC.
N lost to follow-up: 0/243 for repetition of SH at post-intervention.
Location: Copenhagen, Denmark.
Participants Number of total participants: 243 participants were randomised, 123 were allocated to case manage-
ment and assertive outreach, and 120 were allocated to TAU.
Profile of participants: mean age 31.0 ± 13.3 years (range: 11-69 years). Three-quarters (n = 184; 75.7%)
were female. Over half (n = 130; 53.5%) had a history of SH (i.e. multiple episodes of SH). Whilst just un-
der half (n = 109; 44.8%) had a history of psychiatric treatment prior to the index attempt, no informa-
tion on psychiatric diagnoses was reported.
Source of participants: patients admitted to acute emergency units, intensive care units, paediatric
units, or psychiatric emergency room units following a suicide attempt.
Inclusion criteria: i) aged 12 years or older; ii) admitted to acute emergency units, intensive care units,
paediatric units, or psychiatric emergency room units following a suicide attempt.
Exclusion criteria: i) living in an institution; ii) admitted to a psychiatric unit for > 14 days; iii) diagnosed
with a schizophrenia-spectrum disorder; iv) diagnosed with severe depression, bipolar disorder, or de-
mentia; v) currently receiving outreach services from social service agencies.
Interventions Intervention: between eight to 20 sessions (duration not reported) of an assertive intervention involving
case management, crisis intervention, as required, problem-solving therapy, and assertive outreach
based on motivational support to encourage patients to attend treatment sessions, assist patients to
attend these sessions, and to improve adherence to after-treatment in addition to TAU. Sessions were
delivered by psychiatric nurses (experience not reported) who received further training (duration not
reported) in suicidology.
Comparator: EUC consisting of six to eight sessions (duration not reported), including a psychiatric as-
sessment and referral to AOD treatment, psychological therapy, and GP treatment, as required. Phar-
macological treatment was also provided, where necessary, through the Centre for Excellence.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report in addition to medical and hospital
records; ii) suicide ascertained from self-report in addition to medical and hospital records.
Notes Source(s) of funding: “This study received funding from the Ministry of Health and Internal Affairs, Den-
mark, the National Board of Social Services, and independent subdivision of The Ministry of Social Af-
fairs and Integration, TrygFoden, and Aase og Ejnar Danielsens Foundation” (Morthorst 2012, p. 6).
Mouaffak 2015
Methods Participants were individually randomised (procedure not reported) stratified by history of suicide at-
tempts to either a remote contact intervention (telephone contact combined with emergency cards
and letters) or TAU.
Location: Bicêtre, France.

Informed decisions.
Mouaffak 2015 (Continued)
Participants Number of total participants: 303 participants were randomised, 152 were allocated to a remote contact
intervention (letters and telephone contact), and 151 were allocated to TAU.
Profile of participants: mean age 38.8 ± 13.1 years (range: not reported). Almost three-quarters (n = 224;
73.9%) were female. Just under half (n = 151; 49.8%) had a history of SH (i.e. multiple episodes of SH).
Almost one-third were diagnosed with a depressive disorder (n = 87; 28.7%) or PTSD (n = 87; 28.7%), fol-
lowed by AUD (n = 18; 5.9%). A minority were diagnosed with a comorbid PD (n = 50; 16.5%).
Source of participants: patients admitted to a psychiatric ED following a suicide attempt.
Inclusion criteria: i) aged 18 years or older; ii) discharged from the ED within 72 hours with a referral to
an outpatient follow-up programme; iii) able to provide consent; iv) able to be contacted by telephone;
v) sufficient language ability.
Exclusion criteria: i) unable to be contacted by telephone (e.g. homeless, incarcerated); ii) insufficient
language ability.
Interventions Intervention: remote contact intervention (letters and telephone contact) consisting of a letter sent
within days post-discharge providing information on scheduled interventions, and a resource card pro-
viding the contact information of a senior psychiatrist available 24 hours. Participants received further
letters one, six, and 11 months' post-discharge. Participants also received telephone contact (duration
not reported) at two weeks, and months one and three post-discharge. The purpose of these calls was
to facilitate collaborative management and foster treatment engagement. PST, crisis management, and
hospital treatment were also provided, if required. Sessions were delivered by psychiatrists (no further
information on experience was reported).
Comparator: TAU (no further details reported) as well as reminder letters one, six, and 11 months' post-
discharge.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report, collateral informant report, and/
or hospital reports; ii) time to repetition of SH ascertained from self-report, collateral informant report,
and/or hospital reports.
Secondary outcome(s): i) service use ascertained from self-report, collateral informant report, and/
or hospital reports; ii) suicide as ascertained from mortality registers; iii) all-cause mortality as ascer-
tained from mortality registers.
Mousavi 2015
Methods Participants were individually randomised (procedure not reported) to either a remote contact inter-
vention (telephone contact) or alternative psychotherapy.
Location: Isfahan, Iran.
intervention (telephone contact), and 26 were allocated to TAU.

Informed decisions.
Mousavi 2015 (Continued)

Profile of participants: mean age 28.3 ± 7.8 years (range: not reported). The majority (n = 48; 87.3%) were
female. All (n = 55; 100%) had a history of SH (i.e. multiple episodes of SH). No information on psychi-
atric diagnoses was reported.
Source of participants: patients admitted to the ED of a general hospital following a suicide attempt.
Inclusion criteria: i) aged 20 years or older; ii) ≥ 2 previous suicide attempts (time-frame not reported);
iii) able to understand the trial procedure; iv) able to provide informed consent; v) sufficient language
ability.
Exclusion criteria: i) diagnosed with dementia or other cognitive impairment according to DSM-IV-TR
criteria; ii) required immediate medical intervention (e.g. emergency surgery); iii) no known contact in-
formation; iv) those unable to be contacted post-intervention; v) those who die during the follow-up
period (other than by suicide).
Interventions Intervention: remote contact intervention (telephone contact) consisting of up to eight telephone calls
(20 minutes) at weeks two and four, and at months two, three, four, five, six, and eight post-discharge.
Therapeutic content included psychoeducation, identification of problems, problem appraisal, stress
management, and referral to a psychiatrist, psychologist, or social worker, as required. Sessions were
delivered by assistant psychiatrists (no further information on experience was reported).
Comparator: face-to-face contact consisting of up to eight sessions (20 minutes) at weeks two and four,
and at months two, three, four, five, six, and eight post-discharge. Therapeutic content included psy-
choeducation, identification of problems, problem appraisal, stress management, and referral to a psy-
chiatrist, psychologist, or social worker, as required.
Length of treatment: eight months.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report; ii) hopefulness as ascertained from
self-report (reverse coded); iii) interest as ascertained from self-report; iv) problem resolution as ascer-
tained from self-report; v) suicidal ideation as ascertained from self-report; vi) suicide (unclear how as-
certained).
Mousavi 2017
Methods Participants were individually randomised (procedure not reported) to either CBT-based psychothera-
py in addition to TAU or TAU alone.
Location: Isfahan, Iran.
psychotherapy in addition to TAU, and 30 were allocated to TAU alone.
Profile of participants: mean age not reported (range: not reported). The majority (n = 42; 70.0%) were
female. All (n = 60; 100%) had a history of SH (i.e. multiple episodes of SH). No information on psychi-
Source of participants: patients hospitalised following a suicide attempt.
Inclusion criteria: i) sufficient language ability; ii) able to provide informed consent.

Informed decisions.
Mousavi 2017 (Continued)

Exclusion criteria: i) diagnosed with dementia or other cognitive impairment according to DSM-IV-TR
criteria; ii) required immediate medical intervention (e.g. emergency surgery); iii) no known contact in-
formation; iv) those unable to be contacted post-intervention; v) those who died during the follow-up
period (other than by suicide).
Interventions Intervention: brief psychotherapy based on principles of ACT and CBT in addition to TAU. Therapy con-
sisted of 10 face-to-face visits in weeks one and two and months two, three, four, five, six, seven, eight,
10, and 12 post-discharge. Therapeutic content included identifying and recognising thoughts that in-
terfered with problem-solving (e.g. all-or-nothing thinking), cognitive restructuring, coping with prob-
lems, acceptance of problems, and cognitive diffusion. Participants were also referred to treatment by
a psychologist, psychiatrist, or social worker, as required. No information on who delivered the inter-
vention, their expertise, or their experience was reported.
Comparator: TAU consisting of referral to the psychiatric emergency unit for review, further referral
to treatment by a psychologist, psychiatrist, or social worker, as required, and telephone contact at
months two, four, six, five, six, seven, eight, 10 and 12 post-discharge.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report; ii) hopelessness as ascertained
from self-report; iii) satisfaction with life as ascertained from self-report; iv) suicidal ideation as ascer-
tained from self-report.
Naidoo 2014
Methods Participants were individually randomised using a computer generated process to either provision of
information and support or TAU.
N lost to follow-up: unclear.
Location: Durban, South Africa.
Participants Number of total participants: 688 participants were randomised, 344 were allocated to provision of in-
formation and support and 344 were allocated to TAU.
Profile of participants: mean age 35.0 years (SD not reported, range: 20-29 years). Three-quarters (n =
516; 75.0%) were female. Information on psychiatric diagnoses was not reported.
Source of participants: patients presenting to the ED and/or admitted to the short- or long-stay wards of
one of two general hospitals following an episode of SH.
Inclusion criteria: i) aged 18 years and older; ii) presenting to the ED and/or admitted to the short- or
long-stay wards of one of two general hospitals following an episode of SH.
Interventions Intervention: based on the SUPRE-MISS model (Fleischmann 2008) consisting of a brief (one hour) infor-
mation and psychoeducation session, and nine follow-up contacts (duration not reported, also modal-
ity not reported) at weeks one, two, four, seven, 11, and months four, six, 12, and 18 months post-dis-
charge. Participants were also paired with a nominated support person who received training (three
sessions of four hours' duration each) in basic counselling and gate-keeping skills. No further informa-
tion on who delivered the intervention, their expertise, or their experience was reported.

Informed decisions.
Naidoo 2014 (Continued)

Comparator: SUPRE-MISS intervention without support persons. Based on the SUPRE-MISS model
(Fleischmann 2008), this consisted of a brief (one hour) information ad psychoeducation session, and
nine follow-up contacts (duration not reported, also modality not reported) at weeks one, two, four,
seven, 11, and months four, six, 12, and 18 months post-discharge.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report using a tool developed for the
SUPRE-MISS trial; ii) suicide (unclear how determined); iii) all-cause mortality (unclear how deter-
mined).
Notes Source(s) of funding: no source(s) of funding reported.
Conflict(s) of interest: no conflict(s) of interest reported.
O'Connor 2015
Methods Participants were individually randomised (method not reported) to either a brief ED-based Collabora-
tive Assessment and Management of Suicidality (CAMS)-based intervention or TAU.
N lost to follow-up: data on repetition of SH not reported. However the authors reported "[w]e complet-
ed 80% of the 1-month follow-up interviews. The 20% who were lost to follow-up did not respond to
our efforts at contacting them through telephone, mail, or email contacts" (O'Connor 2015, p.430).
Location: unclear (USA).
Participants Number of total participants: 30 participants were randomised, 15 were allocated to a brief intervention
(based on principles of CAMS and DBT), and 15 were allocated to TAU.
Profile of participants: mean age 41.3 ± 13.8 years (range: not reported). Just over one-quarter (n = 8;
26.7%) were female. No information on psychiatric diagnoses was reported.
Source of participants: patients medically admitted to a medical or surgical ward of a trauma hospital
following a suicide attempt.
Inclusion criteria: i) 15 years of age or older; ii) medically admitted to a medical or surgical ward of a
trauma hospital following a suicide attempt; iii) sufficient language ability; iv) able to provide informed
consent.
Exclusion criteria: i) denied making an index attempt; ii) insufficient language ability; iii) imprisoned; iv)
assessed as either too cognitively impaired, delirious, or psychotic to respond to a psychosocial inter-
vention by clinical personnel.
Interventions Intervention: brief, one-off intervention (average duration 43.98 ± 12.87 minutes) based on principles
from CAMS. Therapeutic content involved collaborative assessment and planning, rapport building,
guided discovery, functional analysis, crisis planning, and linkage to outpatient mental health services,
as required. No information on who delivered the intervention, their expertise, or their experience was
reported.
Comparator: TAU. No specific information on TAU content was reported.
Outcomes Primary outcome(s): i) satisfaction with treatment as measured by the Patient Satisfaction Question-
naire.

Informed decisions.
O'Connor 2015 (Continued)

Secondary outcome(s): i) suicidal ideation as measured by the BSS; ii) motivation to change as mea-
sured by the Stages of Change Questionnaire; iii) hopelessness as measured by the Reasons for Living
Inventory (reverse scored).
Notes Source(s) of funding: "The current study was supported by grants T32HD057822 (PI: Rivara) from the Eu-
nice Kennedy Shriver National Institute of Child Health & Human Development and K24MH086814 (PI:
Zatzick) from the National Institutes of Mental Health" (O'Connor 2015, p.432).
O'Connor 2017
Methods Participants were individually randomised (1:1) using a web-based, minimisation procedure to either a
brief ED-based guided integrated motivational-volitional-focused intervention or TAU.
N lost to follow-up: 6/518 (1.2%) for repetition of SH by the six-month follow-up assessment.
Location: Edinburgh, UK.
Participants Number of total participants: 518 participants were randomised, 259 were allocated to a brief interven-
tion (volitional help sheet), and 259 were allocated to TAU.
female and had a history of SH (i.e. multiple episodes of SH (n = 329; 63.5%). No information on psychi-
Source of participants: patients admitted overnight to an acute medical unit of a general hospital fol-
lowing a suicide attempt.
Inclusion criteria: i) 16 years of age or older; ii) ≥ 1 self-reported episode of SH.
Exclusion criteria: i) assessed as medically unfit for interview; ii) insufficient language ability; iii) already
participating in other trials being conducted within the hospital; iv) were treated within the ED without
an admission.
Interventions Intervention: brief, volitional help-sheet (VHS) intervention consisting of a one-off assessment (dura-
tion not reported) in addition to TAU. Participants were provided with a list of common situations in
which they may be tempted to engage in SH together with a list of potential alternative behaviours.
Participants then drew links between any situation that applied to them and any one of the listed alter-
native behaviours. Participants could make as many links as desired. At the conclusion of the assess-
ment, participants took a copy of the VHS home. At approximately two months' post-discharge, partic-
ipants received a booster VHS by mail. Sessions were delivered by clinical staff (no further information
on their expertise or experience was reported).
Comparator: TAU consisting of a one-off psychosocial assessment (duration not reported) undertaken
by the liaison psychiatry service. Following this, participants were either transferred to inpatient psy-
chiatric care, or referred for outpatient psychiatric treatment, voluntary sector follow-up, or primary
care follow-up, as required.
Outcomes Primary outcome(s): i) repetition of SH ascertained from medical records; ii) number of repeat SH
episodes ascertained from medical records; iii) incremental cost per SH event averted.
Secondary outcome(s): i) time to SH repetition ascertained from medical records.
Notes Source(s) of funding: "The trial was funded by a grant from the Chief Scientist Office, Scotland
(CZH/4/704)" (O'Connor 2017, p.459).
Informed decisions.
O'Connor 2017 (Continued)

Conflict(s) of interest: "We declare no competing interests" (O'Connor 2017, p.459).
O'Connor 2020
Methods Participants were individually randomised using a minimisation procedure, stratified by sex and histo-
ry of SH to either a brief ED-based intervention (teachable moment brief intervention) or TAU.
Location: Nashville, TN, USA.
Participants Number of total participants: 48 participants were randomised, 23 were allocated to a brief intervention
(teachable moment brief intervention), and 25 were allocated to TAU.
Profile of participants: mean age 42.6 ± 2.6 years (range: not reported). Over half (n = 26; 54.2%) were fe-
male. No information on psychiatric diagnoses was reported.
Source of participants: patients admitted to an acute medical unit of a general hospital following a sui-
cide attempt.
Inclusion criteria: i) aged 18 years or older; ii) admitted to an acute medical unit of a general hospital
following a suicide attempt; iii) sufficient language ability; iv) able to provide informed consent.
Exclusion criteria: i) insufficient language ability; ii) imprisoned; iii) assessed as either too cognitively
impaired, delirious, or psychotic to respond to a psychosocial intervention by clinical personnel.
Interventions Intervention: brief intervention based on principles of CAMS, consisting of nine components (30 min-
utes' duration in total). Therapeutic content involved collaborative assessment and planning, rapport
building, guided discovery, functional analysis, crisis planning, and linkage to outpatient mental health
services, as required. Sessions were delivered by clinicians (no further information on expertise or ex-
perience was reported).
Comparator: TAU. No specific information on TAU content was reported.
Length of treatment: 30 minutes.
Outcomes Primary outcome(s): i) satisfaction with treatment as measured by the Client Satisfaction Question-
naire.
Secondary outcome(s): i) repetition of SH according to self-report using the SASII; ii) interpersonal func-
tioning as measured by the Interpersonal Needs Questionnaire; iii) motivation to change as measured
by the Stages of Change Questionnaire; iv) hopelessness as measured by the Reasons for Living Inven-
tory (reverse scored); v) services use ascertained from the Health Services and Medication Use mea-
sure; vi) suicidal ideation as measured by the BSSI.
Notes Source(s) of funding: "This work was supported by the American Foundation for Suicide Prevention
[grant number YIG-0-098-13]" (O'Connor 2020, p.117).
Owens 2020

Informed decisions.
Owens 2020 (Continued)
Methods Participants were individually randomised (1:1) using a computer adaptive minimisation procedure
balanced for: i) number of previous episode of SH leading to hospital treatment prior to study entry
(i.e. one vs. > 1); ii) method of SH at the index episode (i.e. self-poisoning vs. self-injury vs. both com-
bined); iii) sex (i.e. male vs. female); iv) age (i.e. < 30 years vs. 30–59 years vs. ≥ 60 years) to either CBT-
based psychotherapy or TAU.
N lost to follow-up: 0/62 (0%) for repetition of SH at six months (as ascertained from hospital records).
Location: Leeds and York, UK.
Participants Number of total participants: 62 participants were randomised, 30 were allocated to PST, and 32 were
allocated to TAU.
Profile of participants: mean age 35.2 ± 13.8 years (range: 18 to 65 years). Over half (n = 40; 64.5%) were
female. Over three-quarters (n = 48; 77.4%) and had a history of SH (i.e. multiple episodes of SH). Whilst
the majority (n = 52; 83.9%) had received mental health treatment, no specific information on psychi-
Source of participants: patients presenting to EDs following an episode of self-harm.
Inclusion criteria: i) 18 years of age or older; ii) living within the catchment area; iii) presented to one of
two EDs following an episode of SH within six weeks prior to trial entry.
Exclusion criteria: i) currently receiving treatment that may interfere with PST; ii) insufficient cognitive
capacity; iii) insufficient language ability; iv) known risk of violence to others; v) unable to be contacted
within eight weeks of the index episode of SH.
Interventions Intervention: manualised PST adapted from Hatcher 2015 and Hatcher 2016, comprising six weekly to
fortnightly sessions (1 hour). Participants could also receive a single booster session (1 hour) between
six to eight weeks following the acute phase. Therapeutic content involved problem orientation, recog-
nising and identifying problems, selecting and defining a problem, generating alternative solutions, de-
cision-making, implementing a SMART (Specific, Measurable, Achievable, Relevant, and Time-bound)
plan, and reviewing progress. Sessions were delivered by mental health nurses or occupational thera-
pists who received training (two days) in delivering the intervention together with ongoing fortnightly
supervision.
Comparator: TAU. This could vary widely, from telephone contact to remind participants of appoint-
ments, to follow-up psychosocial assessments, referral to other services (e.g. AOD), as required, and
participation in group-based therapy. Any form of TAU was received by 69%, most commonly, commu-
nity mental health contacts.
Concomitant medications: no information on concomitant medications reported.
Length of treatment: up to 12 weeks (for the acute phase), up to 20 weeks (including ‘booster’ phase).
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report and hospital records.
Secondary outcome(s): i) repetition of SH ascertained from self-report; ii) other serious adverse events
ascertained from hospital records; iii) treatment adherence as measured by the number of sessions at-
tended; iv) health-related quality of life as measured by the SF-36; v) health economics data.
Notes Source(s) of funding: "This work represents independent research funded by the UK National Insti-
tute for Health Research in the form of a Research for Patient Benefit grant (NIHR Project Number PB-
PG-0610-22267). The treatment costs of the PST were funded by the Leeds and York Partnership NHS
Foundation Trust" (Owens 2020, p.13).
Conflict(s) of interest: "The authors declare that they have no competing interests" (Owens 2020, p.13).
Other: It should be noted that one of the authors (SH) wrote the therapeutic manual, and has been in-
volved in two further trials of this therapeutic approach.

Informed decisions.
Patsiokas 1985
Methods Participants were individually randomised (method not reported) to either cognitive restructuring, PST,
or TAU.
N lost to follow-up: not reported.
Location: Charleston, SC, USA.
Participants Number of total participants: 15 participants were randomised, 5 were allocated to cognitive restructur-
ing, 5 were allocated to PST, and 5 were allocated to TAU.
Profile of participants: not reported.
Source of participants: patients admitted to a psychiatric ward following a suicide attempt.
Inclusion criteria: i) admitted to a psychiatric ward following a suicide attempt.
Exclusion criteria: i) diagnosed with psychosis; ii) diagnosed with substance abuse.
Interventions Intervention (cognitive restructuring): up to 10 sessions (60 minutes) of cognitive restructuring delivered
according to the model by Beck 1976. Therapeutic content included identifying automatic thoughts,
cognitive distortions, and discussing the validity of assumptions, beliefs, and attitudes that led to their
suicide attempt. Sessions were delivered by the same therapist for all three conditions (no further in-
formation on expertise or experience was reported).
Intervention (PST): up to 10 sessions (60 minutes) of PST according to D'Zurilla 1971. Therapeutic
content included orientation, problem definition and formulation, generation of alternatives, deci-
sion-making, and verification. Sessions were delivered by the same therapist for all three conditions
(no further information on expertise or experience was reported).
Comparator: TAU (number and duration of sessions not reported) involving open discussions about sui-
cidal behaviour, problems, and daily life.
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) cognitive flexibility as measured by
the Alternative Uses Test; iii) hopelessness as measured by the BHS; iv) problem-solving as measured
by the MEPS; v) suicidal ideation as measured from self-report using the Self-Monitoring of Suicidal
Ideation and the BSSI.
Notes Source(s) of funding: no sources of funding reported.
Conflict(s) of interest: no conflicts of interest reported.
Priebe 2012
Methods Participants were individually randomised using a computer-generated algorithm to either DBT or TAU.
allocated to TAU.

Informed decisions.
Priebe 2012 (Continued)

Profile of participants: mean age 32.2 ± 10.8 years (range: not reported). The majority (n = 70; 87.5%)
were female.
Source of participants: referrals to a specialist DBT service.
Inclusion criteria: i) aged 16 years or older; ii) engaged in SH on ≥ 5 days in the year prior to trial entry;
iii) diagnosed with ≥ 1 PD.
Exclusion criteria: i) diagnosed with a severe learning disability that would interfere with the ability to
benefit from DBT; ii) insufficient language ability.
Interventions Intervention: DBT delivered according to Linehan 1993, involving weekly individual (60 minutes) and
group-based skills training (2 hours). Out-of-hours telephone skills training was also available, as re-
quired. Therapeutic content involved CBT, mindfulness, validation, supportive therapeutic techniques,
and skills training. No information on who delivered the intervention, their expertise, or their experi-
ence was reported.
Comparator: TAU involving referral back to the referee agency where the participant was encouraged to
engage with any treatment other than DBT, including psychotherapy, referral to psychiatrists, mental
health teams, counsellors, GPs, or other user-run support services, as required.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report.
Secondary outcome(s): i) BPD symptoms as measured by the Zanarini Rating Scale for Borderline Per-
sonality Disorder; ii) quality of life as measured by the Manchester Short Assessment of Quality of Life;
iii) symptoms as measured by the Brief Psychiatric Rating Scale and the BSI; iv) services use as mea-
sured by the Client Service Receipt Inventory; v) treatment adherence as measured by the number of
sessions attended.
Notes Source(s) of funding: “This paper... [was] funded by the National Institute for Health Research (NIHR)
under its Research for Patient Benefit Programme (grant reference No. PB-PG-0906-10540). All authors
were funded by this grant with the exception of K.B. whose contribution was funded by the NIHR Doc-
toral Research Fellowship Scheme” (Priebe 2012, p. 364).
Conflict(s) of interests: no conflicts of interests reported.
Sahin 2018
Methods Participants were individually randomised (method not reported) to either DBT, psychodynamic psy-
chotherapy, or TAU.
N lost to follow-up: data on repetition of SH not reported.
Location: Stockholm, Sweden.
Participants Number of total participants: 106 participants were randomised, 35 were allocated to DBT, 36 were al-
located to object-relational psychotherapy (psychodynamic psychotherapy), and 35 were allocated to
TAU.
Profile of participants: mean age 29.5 ± 7.7 years (range: 19-50 years). All (n = 106; 100%) were female,
had a history of SH (i.e. multiple episodes of SH), and were diagnosed with BPD. A minority were also
diagnosed with the following comorbid psychiatric disorders: major depression (n = 40; 37.7%), panic
disorder (n = 40; 37.7%), PTSD (n = 28; 26.4%), avoidant PD (n = 20; 18.9%), paranoid PD (n = 13; 12.3%),
dependent PD (n = 9; 8.5%), and obsessive-compulsive PD (n = 9; 8.5%).
Source of participants: patients receiving outpatient psychiatric treatment who self-reported a history
of engaging in multiple episodes of SH.

Informed decisions.
Sahin 2018 (Continued)

Inclusion criteria: i) female; ii) aged 19-50 years; iii) diagnosed with BPD according to DSM-IV criteria; iv)
≥ 2 suicide attempts with ≥ 1 of these within the six months preceding trial entry.
Exclusion criteria: i) diagnosed with SUD, psychosis, major depression with melancholic features, a life-
threatening eating disorder, dementia, or other neurological disorder.
Interventions Intervention (DBT): DBT delivered according to Linehan 1993, comprising sessions of both individual
therapy and group-based therapy. Mean number of sessions 44.5 ± 33.4 (range: 0-155). No specific in-
formation on therapeutic content reported. Sessions were delivered by masters-level psychiatrists,
psychologists, psychiatric social workers, psychiatric nurses, psychiatric nurse assistants, nurses, or oc-
cupational therapists who received training (duration not reported) in delivering DBT, who reached a
minimum score of 3.7 or higher on the DBT Global Rating Scale, who had an average of 22 years clinical
experience, and who received ongoing supervision (duration not reported).
Intervention (object-relational psychotherapy): consisting of psychodynamic psychotherapy. Mean num-

ber of sessions 58.0 ± 65.1 (range: 0-236). Therapeutic content included: structural interview according
to Clarkin 1999, comprising establishing the therapeutic contract, setting the framework of treatment,
techniques to explore mental imagery, and interpersonal relationship therapy. Sessions were delivered
by masters-level psychiatrists, psychologists, psychiatric social workers, psychiatric nurses, psychiatric
nurse assistants, nurses, or occupational therapists who received training (duration not reported) in
delivering the intervention, who had an average of 22 years clinical experience, and who received on-
going supervision (duration not reported).
Comparator: TAU. Consisted of maintenance therapy. No specific detail was reported.
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report using the PHI; ii) BPD symptoms
as measured by the DSM-IV and ICD-10 Personality Disorders Interview; iii) general functioning as mea-
sured by the GAF; iv) general psychiatric symptoms as measured by the SCL-90.
Conflict(s) of interest: no conflicts of interest reported.
Salkovskis 1990
Methods Participants were individually randomised using a predetermined method of sampling without re-
placement and sealed envelopes to either CBT-based psychotherapy or TAU.
N lost to follow-up: 0/20 (0%) for repetition of SH by the six-month assessment.
Location: Leeds, UK.
Participants Number of total participants: 20 participants were randomised, 12 were allocated to CBT-based psy-
chotherapy, and 8 were allocated to TAU.
Profile of participants: mean age 27.2 ± 6.7 years (range: 16-65 years). Half (n = 10; 50.0%) were female.
All (n = 20; 100%) had a history of SH (i.e. multiple episodes of SH). Whilst the majority (n = 19; 95.0%)
had previous psychiatric treatment (inpatient: n = 7, 35.0%; outpatient: n = 12, 60.0%), no information
on psychiatric diagnoses was reported.
Source of participants: patients referred by the duty psychiatrist following an episode of self-poisoning
using antidepressants, and who were assessed in an A&E department following this episode.
Inclusion criteria: i) aged 16-65 years; ii) of fixed abode and living within the catchment area; iii) antide-
pressants were taken as part of the self-poisoning episode; iv) ≥ 2 or more suicide attempts preceding

Informed decisions.
Salkovskis 1990 (Continued)

trial entry; v) Buglass and Horton Risk of Repetition Scale score ≥ 4. Participants had to fulfil at least 2
criteria to be included.
Exclusion criteria: i) not requiring immediate psychiatric treatment; ii) diagnosed with psychosis; iii) di-
agnosed with a serious organic illness.
Interventions Intervention: domiciliary (home-based) CBT-based problem-solving psychotherapy consisting of five

(60 minutes) sessions. Therapeutic content involved identifying problems, priority setting, generating
alternative solutions, and goal-setting. Sessions were delivered by community psychiatric nurses (no
further information on experience was reported).
Comparator: TAU. No further information on number, duration, or therapeutic content reported.
Length of treatment: one month.
Outcomes Primary outcome(s): i) repetition of SH ascertained from hospital records; ii) anxiety, tension, and fa-
tigue measured by the Profile of Mood State; iii) depression measured by the BDI; iv) hopelessness
measured by the BHS; v) problem-solving measured by the Personal Questionnaire Rapid Scaling Tech-
nique; vi) suicidal ideation measured by the BSSI; vii) suicide (unclear how ascertained).

Conflict(s) of interests: no conflicts of interest reported.
Slee 2008
Methods Participants were individually randomised using a computer-based random number generator to ei-
ther CBT-based psychotherapy in addition to TAU or TAU alone.
N lost to follow-up: 8/90 (8.9%) for repetition of SH data by the six-month assessment.
Location: Leiden, the Netherlands.
chotherapy in addition to TAU, and 42 were allocated to TAU.
female, and were diagnosed with any mood disorder (n = 73; 89.0%), followed by any anxiety disorder
(n = 45; 54.9%), any eating disorder (n = 14; 17.1%), alcohol/drug misuse (n = 14; 17.1%), and somato-
form disorder (n = 3; 3.7%). Three-quarters (n = 62; 75.6%) had a history of SH (i.e. multiple episodes of
SH prior to trial entry).
Source of participants: patients presenting to hospital/mental health centre following an episode of SH.
Inclusion criteria: i) recently engaged in SH; ii) aged 15-35; iii) sufficient language ability; iv) residing
within the catchment area.
Exclusion criteria: i) diagnosed with a psychiatric disorder requiring intensive inpatient treatment; ii) di-
agnosed with a cognitive impairment.
Interventions Intervention: CBT-based psychotherapy consisting of 12 sessions (duration not reported) in addition to
TAU. Therapeutic content included cognitive restructuring, problem-solving skills, and behavioural ac-
tivation. Sessions were delivered by experienced CBT practitioners (no further information on expertise
was reported).
Comparator: TAU consisting of medication, psychotherapy, or hospitalisation, as required.
Length of treatment: 5.5 months.

Informed decisions.
Slee 2008 (Continued)
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report.
Secondary outcome(s): i) anxiety as measured by the anxiety subscale of the SCL-90; ii) depression as
measured by the BDI; iii) problem-solving as measured by the Coping Inventory for Stressful Situations;
iv) self-esteem as measured by the Robson Self-Concept Questionnaire, Short version; v) suicidal cogni-
tions as measured by the Suicide Cognition Scale; vi) treatment adherence as measured by the number
of sessions attended; vii) suicide (unclear how ascertained).
Notes Source(s) of funding: “Support for the study was provided by The Netherlands Organisation for Health
Research and Development (AonMw) (contract grant number: 2100.0068)" (Slee 2008, p. 210).
Other: Repetition of SH data provided by participants was subjected to reliability analysis by comparing
self reports to hospital records and information from treatment sessions.
Sreedaran 2020
Methods Participants were individually randomised (1:1) using a computer-based procedure in blocks of ten to
either telephone-based psychotherapy or a remote contact intervention (telephone contact).
Location: Bangalore and New Delhi, India.
Participants Number of total participants: 28 participants were randomised, 15 were allocated to telephone-based
psychotherapy in addition to TAU, and 13 were allocated to a remote contact intervention (telephone
contact).
Profile of participants: median age 33.7 years (range: 18-55 years). Three-quarters (n = 21; 75.0%)
were female. Just under one-third (n = 9; 32.1%) were diagnosed with a common psychiatric disorder
(e.g. MDD, any anxiety disorder, adjustment disorder). A minority (n = 1; 3.6%) were diagnosed with a
personality disorder. Just under one-third (n = 9; 32.1%) were not diagnosed with a psychiatric disor-
der.
Source of participants: patients presenting to a general hospital and who had made a recent (within one
month) suicide attempt.
Inclusion criteria: i) aged 18-55 years; ii) those with a history of SH (i.e. multiple episodes of attempted
suicide); iii) sufficient language ability (English, Hindi, Kannada, Telugu, or Tamil); iv) recent (within one
month preceding trial entry) suicide attempt.
Exclusion criteria: i) diagnosed with psychosis or SUD according to the MINI, version 6, criteria; ii) diag-
nosed with an unstable medical illness; iii) diagnosed with a cognitive impairment.
Interventions Intervention: manualised telephone-based psychosocial intervention consisting of three telephone

calls (12-15 minutes) incorporating principles from supportive therapy, CBT-based psychotherapy, and
DBT. Therapeutic content involved mental status examination, reflective listening, problem-solving,
counselling, and treatment adherence. Sessions were delivered by postgraduate psychologists who re-
ceived training (duration not reported) in delivering the intervention and ongoing supervision.
Comparator: remote contact intervention consisting of three telephone calls (two to five minutes) de-
signed to encourage follow-up with mental health and other services, as required.
Length of treatment: 24 days.
Outcomes Primary outcome(s): i) treatment adherence as measured by dropout rates; ii) satisfaction with treat-
ment as measured by an idiosyncratic scale.

Informed decisions.
Sreedaran 2020 (Continued)

Secondary outcome(s): i) repetition of SH (unclear how ascertained); ii) suicide (unclear how ascer-
tained).
Notes Source(s) of funding: "This study was funded by the Indian Council of Medical Research (ICMR), with re-
search oversight by a National Coordination Unit, under Capacity Building Projects of National Mental
Health Program, ICMR-NMHP" (Sreedaran 2020, p.5).
Conflict(s) of interest: "The authors declared no potential conflicts of interest with respect to the re-
search, authorship, and/or publication of this article" (Sreedaran 2020, p.5).
Stewart 2009
Methods Participants were individually randomised by drawing names from a hat to either CBT- or PST-based
psychotherapy or TAU.
Location: Brisbane, QLD, Australia.
chotherapy, 12 were allocated to PST, and 9 were allocated to TAU.
Profile of participants: mean (SD) age not reported (range: 20-58 years). Just over half (n = 17; 53.1%)
were female. No information on psychiatric diagnoses were reported.
Source of participants: patients admitted a general hospital following a suicide attempt.
Inclusion criteria: i) suicide attempt with self-reported suicide intent; ii) admitted to hospital.
Exclusion criteria: i) diagnosed with an intellectual disability; ii) current diagnosis of mania, psychosis,
or both; iii) under 18 years. Correspondence with authors further clarified that one participant was sub-
sequently excluded after randomisation due to being a frequent repeater of SH, possibly in the context
of BPD.
Interventions Intervention (CBT- or PST-based psychotherapy): consisting of four weekly individual sessions of cogni-
tive-behavioural therapy (60 minutes) or seven weekly sessions of PST (60 minutes). CBT-based psy-
chotherapy was manualised and based on elements of both Beck’s CBT (Beck 1976) and Ellis’ theory of
rational emotive therapy (Ellis 1986). PST was also manualised and was based on the 6-step model of
D'Zurilla 1971. Specific information on therapeutic content was not reported, however. Sessions were
delivered by "the researcher" (Stewart 2009, p.542) (no further information on expertise or experience
was reported).
Comparator: TAU consisting of treatment by the hospitals' acute care teams.
Length of treatment: two months.
Outcomes Primary outcome(s): i) hopelessness as measured by the BHS; ii) problem-solving as measured by the
Social Problem-Solving Inventory Revised; iii) treatment adherence as measured by the number of ses-
sions attended; iv) satisfaction with treatment as measured by the CSQ-8; v) suicidal ideation as mea-
sured by the BSSI; vi) suicide (unclear how ascertained).


Informed decisions.
Tapolaa 2010
Methods Participants were individually randomised using a coin toss to either CBT-based psychotherapy or TAU.
N lost to follow-up: 0/16 (0%) for repetition of SH by the six-month follow-up assessment (following cor-
respondence).
Location: Jyväskylä, Finland.
chotherapy, and 7 were allocated to TAU.
Profile of participants: average age 33.2 years (unclear if mean or median) (range: 18-65 years). All (n =
16; 100%) were female. Although no information on psychiatric diagnoses were reported, all (n = 16;
100%) were prescribed medication.
Source of participants: admissions to an ED following an episode of SH.
Inclusion criteria: i) aged 18-65 years; ii) sufficient language ability; iii) living within the catchment area.
Interventions Intervention: ACT solution-focused brief therapy consisting of four weekly sessions (duration not re-
ported) in addition to TAU. Therapeutic content involved meditation, identification of problems, strate-
gies to solve these problems, reflection on alternative methods of problem-solving, providing motiva-
tion to solve these problems, frustration tolerance exercises, and identity assimilation exercises. Ses-
sions were delivered by advanced level psychology students who received 36 hours of training in deliv-
ering ACT.
Comparator: TAU consisting of four weekly sessions (duration not reported). Correspondence with trial
authors clarified that TAU involved psychiatric outpatient treatment in the form of supportive sessions
with a mental health nurse in addition to pharmacological treatment, as required.
Length of treatment: four weeks.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report using the SASII.
Secondary outcome(s): i) anxiety measured by the BAI; ii) depression measured by the BDI; iii) emotion-
al avoidance measured by the AAQ; iv) emotional regulation measured by the DERS; v) health-related
quality of life measured by the 15D; vi) suicide (unclear how ascertained).

Conflict(s) of interests: no information on conflicts of interest reported.
Torhorst 1987
Methods Participants were individually randomised (method not reported) to either continuity of care by the
same therapist or alternative psychotherapy (treatment by a different therapist).
N lost to follow-up: 5/141 (3.5%) for repetition of SH data by the 12 month follow-up assessment.
Location: Munich, Germany.
Participants Number of total participants: 141 participants were randomised, 68 were allocated to crisis intervention
followed by outpatient follow-up by the same therapist, and 73 were allocated to crisis intervention fol-
lowed by outpatient follow-up by a different therapist.

Informed decisions.
Torhorst 1987 (Continued)

Profile of participants: average age not reported, range: 18-65 years. Over half (n = 98; 63.1%) were fe-
male. Just under half (n = 68; 48.2%) had a history of SH (i.e. multiple episodes of SH).
Source of participants: patients hospitalised following a suicide attempt by self-poisoning.
Inclusion criteria: i) admitted to the toxicology department of a hospital following a suicide attempt by
acute intoxication.
Exclusion criteria: i) diagnosed with psychosis.
Interventions Intervention: short crisis intervention during hospital stay followed by 12 weekly outpatient appoint-
ments with the same therapist (duration not reported). Therapeutic content involved a motivational in-
terview, as well as a letter and assessment of motivation towards therapy delivered by the same thera-
pist. Sessions were delivered by therapists trained (duration not reported) in psychotherapy or behav-
iour therapy (further information on expertise not reported).
Comparator: short crisis intervention during hospital stay followed by outpatient appointments with
a different therapist (both the number and duration of these appointments were not reported). Thera-
peutic content involved a motivational interview, as well as a letter and assessment of motivation to-
wards therapy delivered by different therapists.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report; ii) depression (unclear how mea-
sured); iii) treatment adherence as measured by the number of sessions attended; iv) suicide (unclear
how ascertained).

Other: in the first phase of this trial, the efficacy of standard care was assessed in terms of compli-
ance. 85 participants were not randomly assigned to this group but were instead “referred routine-
ly” (Torhorst 1987, p. 53).
Torhorst 1988
Methods Participants were individually randomised (method not reported) to either long-term (over 12 months)
or short-term (over 12 weeks) psychotherapy.
Location: Munich, Germany.
Participants Number of total participants: 80 participants were randomised, 40 were allocated to long-term psy-
chotherapy, and 40 were allocated to short-term psychotherapy.
Profile of participants: average age not reported, range: 18-65 years. All (n = 80; 100%) had a history of
SH (i.e. multiple episodes of SH).
Source of participants: patients hospitalised following an episode of self-poisoning and who were re-
ferred to the liaison service of a toxicological ward.
Inclusion criteria: i) sufficient language ability; ii) living within commuting distance; iii) ≥ 1 suicide at-
tempt preceding trial entry.
Exclusion criteria: i) diagnosed with endogenous psychosis; ii) already receiving psychotherapeutic
treatment (in- or outpatient); iii) overdose involving use of illicit drugs.

Informed decisions.
Torhorst 1988 (Continued)
Interventions Intervention: long-term psychotherapy involving one session (duration not reported) per month over
a period of 12 months in addition to a brief crisis intervention (duration not reported) delivered three
days after admission. Sessions were delivered by psychiatric attendants (no further information on ex-
Comparator: short-term psychotherapy involving 12 weekly sessions (duration not reported) over a pe-
riod of three months in addition to a brief crisis intervention (duration not reported) delivered three
days after admission.
Length of treatment: for the experimental arm, 12 months; for the control arm, 3 months.
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) depression (unclear how mea-
sured); iii) general symptomatology (unclear how measured); iv) treatment adherence as measured by
the number of sessions attended.
Notes Source(s) of funding: “Supported by a grant from the FRG Ministry for Research and Technolo-
gy” (Torhorst 1988; p. 419).
Turner 2000
Methods Participants were individually randomised (method not reported) to either DBT or alternative psy-
chotherapy.
N lost to follow-up: 0/24 (0%) for repetition of SH by the post-intervention assessment.
Location: Philadelphia, PA, USA.
allocated to alternative psychotherapy (client-centred psychotherapy).
Profile of participants: average age 22.0 years (SD not reported) (range: 18-27 years). The majority (n =
19; 79.2%) were female. Almost all (n = 23; 95.8%) were diagnosed with an Axis I disorder, including:
dysthymia with a comorbid generalised anxiety disorder (n = 17), MDD (n = 3), and dysthymia (n = 3). Al-
most all (n = 23; 95.8%) were also diagnosed with a comorbid Axis II disorder, including: dependent PD
(n = 9), histrionic PD (n = 6), narcissistic PD (n = 6), schizotypal PD (n = 3), ASPD (n = 2), paranoid PD (n
= 2), and compulsive PD (n = 1). Three-quarters (n = 18; 75.0%) were also diagnosed with AUD misuse,
83.3% (n = 20) were diagnosed with SUD.
Source of participants: patients admitted to hospital following a suicide attempt.
Inclusion criteria: i) diagnosed with BPD according to both the Diagnostic Interview for Borderlines and
the Personality Disorders Examination criteria; ii) admitted to hospital following a suicide attempt; iii)
able to provide written informed consent; iv) consented to randomised assignment.
Exclusion criteria: i) diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, organic
mental disorder, or mental retardation.
Interventions Intervention: DBT delivered according to Linehan’s manualised protocol (Linehan 1993) modified to in-
clude psychodynamic techniques to conceptualise patients’ behavioural, emotional, and relationship
schema. Additionally, no group skills training sessions were provided. Instead, participants received six
sessions (duration not reported) of individual therapy to provide interpersonal skills training focusing
on the identification of significant persons in the participants’ environment, including problems in rela-
tionships and with family. Sessions were delivered by therapists with an average of 22 years clinical ex-
perience working in family systems, and in delivering client-centred and psychodynamic therapy. Ther-
apists also received 12 sessions of training in delivering DBT over three months.

Informed decisions.
Turner 2000 (Continued)

Comparator: client-centred therapy based on Carkhuff 1969. Therapeutic content involved a SH/sui-
cide contract, emphatic understanding, provision of a supportive atmosphere to enable individuation,
stress management, and relapse prevention. Participants also received six sessions (duration not re-
ported) of interpersonal skills training focusing on the identification of significant persons in the partic-
ipants’ environment, including problems in relationships and with family.
Concomitant medications: were permitted. The majority (n = 19, 71.2%) were prescribed some form of
psychiatric medication. A slightly greater proportion of those allocated to TAU were prescribed medica-
tion (91.7% and 66.7%, respectively).
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report; ii) anger measured by the Target
Behavior Ratings; iii) anxiety measured by the Beck Anxiety Inventory; iv) depression as measured by
the BDI; v) general symptomatology measured by the Brief Psychiatric Rating Scale; vi) impulsiveness
measured by the Target Behavior Ratings; vii) suicidal ideation measured by the BSSI.

Tyrer 2003
Methods Participants were individually randomised using a computer-based allocation sequence with a random
blocking procedure stratified by hospital and parasuicide risk to either CBT-based psychotherapy or
TAU.
N lost to follow-up: 50/480 (10.4%) for repetition of SH data at post-intervention.
Location: Glasgow, Edinburgh, Nottingham, West London, and South London, UK.
Participants Number of total participants: 480 participants were randomised, 239 were allocated to manual-assisted
Profile of participants: average age 32.0 ± 11.0 years (range: 16-65 years). The majority (n = 326; 67.9%)
were female. Just under half (n = 202; 42.1%) were diagnosed with any PD.
Source of participants: patients presenting to hospital following an episode of SH.
Inclusion criteria: i) aged 16-65 years; ii) history of SH prior to trial entry; iii) able to provide informed
consent; iv) sufficient language ability; v) lives in the catchment area; vi) available for follow-up.
Exclusion criteria: i) diagnosed with an organic disorder, AOD dependence, schizophrenia or bipolar af-
fective disorder group of according to ICD-10 diagnostic codes; ii) required psychiatric hospitalisation.
Interventions Intervention: manual-assisted CBT-based psychotherapy consisting of up to seven sessions (five ses-
sions during the acute phase, and two further 'booster' sessions; duration not reported). Therapeu-
tic content involved an evaluation of the most recent suicide attempt, crisis skills, PST, cognitive tech-
niques for emotional, and negative thinking management, and the development of relapse prevention
strategies. Sessions were delivered by duty therapists (no further information on expertise or experi-
ence was reported).
Comparator: TAU involving psychiatric assessment, outpatient care, occasional day-patient care, refer-
ral to GP, or a combination of these.
Length of treatment: up to 3 months (for the acute phase); up to 6 months (including ‘booster’ phase).
Outcomes Primary outcome(s): i) repetition of SH according to SH and as supplemented by GP notes, hospital

records or both; ii) anxiety as measured by the HADS; iii) depression as measured by the HADS; iv)
Informed decisions.
Tyrer 2003 (Continued)

hopelessness as measured by the BHS; v) general functioning as measured by the GAS; vi) social func-
tioning as measured by the SFQ; vii) quality of life as measured by the EuroQoL; viii) symptomatology,
including personality disorder symptomatology, as measured by the CSRI; ix) suicide (unclear how as-
certained).
Notes Source(s) of funding: “The POPMACT study is funded by the Medical Research Council of the United
Kingdom” (Tyrer 2003, p. 67).
Vaiva 2006
Methods Participants were individually randomised using a computer-based pseudo-random numbers list in
opaque sealed envelopes to either a remote contact intervention (telephone contact) or TAU.
Location: Lille, France.
intervention (telephone contact) in addition to TAU, and 312 were allocated to TAU.
Profile of participants: mean age 35.7 ± 11.3 years (range: 18-65 years). The majority (n = 441; 72.9%)
were female. A minority (n = 54; 9.0%) had a history of SH (i.e. multiple episodes of SH). No information
on psychiatric diagnoses reported.
Source of participants: patients presenting to hospital following a drug overdose.
Inclusion criteria: i) aged 18-65 years; ii) hospitalised following a suicide attempt by drug overdose; iii)
examined by a psychiatrist who agreed to patients’ discharge; iv) able to provide name of GP; v) able to
be contacted by phone; vi) able to provide written consent.
Exclusion criteria: i) homeless; ii) addicted to illicit drugs.
Interventions Intervention: remote contact intervention (telephone contact) consisting of a single telephone call (ei-
ther at one or three months' post-discharge; duration not reported) to review the ED-recommended
treatment in addition to TAU. Where participants found the treatment recommended during their hos-
pitalisation too difficult to follow, a new regimen was suggested. For those at high risk of suicide, an ur-
gent appointment was made at the emergency department where the patient initially received treat-
ment. No therapy other than support was provided. Sessions were delivered by psychiatrists with a
minimum of 5 years experience working with suicidal persons.
Comparator: TAU typically involving referral to the participants’ GP.
Length of treatment: single telephone call at one or three months.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report and hospital records; ii) suicide (un-
clear how ascertained).
Notes Source(s) of funding: “This study was funded by a hospital clinical research grant (PHRC98), a state re-
gion contract plan, a subsidy from the regional hospitalization agency” (Vaiva 2006, p. 1245).

Informed decisions.
Vaiva 2018
Methods Participants were individually randomised using a computer-based pseudo-random numbers list using
a blocking procedure to either a remote contact intervention (telephone contact combined with emer-
gency cards and letters) or TAU.
N lost to follow-up: data on repetition of SH not reported.
Location: various locations, France.
intervention (crisis card, postcards and/or telephone contact) in addition to TAU, and 943 were allocat-
ed to TAU.
Profile of participants: mean age 38.3 ± 13.3 years (range not reported). Almost two-thirds (n = 361;
63.4%) were female. Just under half (n = 452; 45.8%) had a history of SH (i.e. multiple episodes of SH).
Almost half (n = 481; 48.7%) were diagnosed with MDD, followed by GAD (n = 136; 13.8%), panic disor-
der (n = 110; 11.1%), dysthymia (n = 103; 10.4%), PTSD (n = 75; 7.6%), any eating disorder (n = 47; 4.8%),
social phobia (n = 44; 4.5%), and mania (n = 36; 3.6%).
Source of participants: patients presenting to the ED following a suicide attempt.
Inclusion criteria: i) presenting to the ED following a suicide attempt.
Exclusion criteria: i) admitted to hospital for ≥ 7 days following the index suicide attempt; ii) unable to
be contacted by telephone; iii) homeless; iv) under guardianship; v) engaged in ≥ 4 suicide attempts
within the three years preceding trial entry.
Interventions Intervention: remote contact intervention consisting of either a crisis card delivered within 24 hours'
post-discharge (for those whose index attempt represented their first episode), telephone contact at
days 10 and 21 post-discharge, or for those who were unable to be contacted by telephone, a series of
postcards mailed at two, three, four, and five months post-discharge (for those who had engaged in
multiple episodes of SH). Participants in addition received TAU. Crisis, telephone contacts, and post-
cards encouraged participants to make contact with the service, if required. No information on who de-
livered the intervention, their expertise, or their experience was reported.
Comparator: TAU consisting of a follow-up appointment within 24-48 hours' post-discharge, and refer-
ral to a psychiatrist or physician, as required.
Outcomes Primary outcome(s): i) repetition of SH (at post-intervention) ascertained from self-report and electron-
ic medical records.
Secondary outcome(s): i) repetition of SH (at 13 months follow-up) ascertained from self-report and
electronic medical records; ; ii) frequency of repeated SH ascertained from self-report and electronic
medical records; iii) time to SH repetition ascertained from self-report and electronic medical records;
iv) adverse events (i.e. repetition of SH, suicide, and/or loss to follow-up).
Notes Source(s) of funding: "This study received a Hospital Clinical Research Grant (PHRC 2009) from the
French Health Ministry" (Vaiva 2018, p.7).
Conflict(s) of interest: "The authors have no conflict of interest to disclose" (Vaiva 2018, p.7).
Van der Sande 1997


Informed decisions.
Van der Sande 1997 (Continued)
Methods Participants were individually randomised using a computer-generated series of random numbers to
either intensive in- and outpatient treatment or TAU.
N lost to follow-up: 0/274 (0%) for repetition of SH data by the 12-month assessment.
Location: Utrecht, the Netherlands.
psychotherapy, and 134 were allocated to TAU.
Profile of participants: mean age 36.3 ± 15.1 years (range not reported). Just over half (n = 158; 57.7%)
were female. Over half (n = 175; 63.9%) also had a history of SH (i.e. multiple episodes of SH). Just over
one quarter (n = 77; 28.1%) were diagnosed with a mood disorder.
Source of participants: patients admitted to hospital following a suicide attempt.
Inclusion criteria :i) admitted to hospital following a suicide attempt; ii) sufficient language ability; iii)
lived in catchment area.
Exclusion criteria: i) engaged in habitual wrist cutting of minor severity; ii) referred for psychiatric inpa-
tient treatment; iii) imprisoned; iv) diagnosed with a substance addiction; v) required recurrent consul-
tations with a liaison psychiatrist during a stay > 2 days on a somatic ward.
Interventions Intervention: brief psychiatric unit admission to a specialist unit for the treatment of suicide attempters
for a period of one to four days. Participants were then offered outpatient treatment based on Haw-
ton and Catalan’s problem-solving approach (Hawton 1987b) (number and duration of sessions not re-
ported). Therapeutic content involved discussing the reasons behind the current suicide attempt, dis-
cussing these reasons with family, partner or both, if required, and changing the ability to cope with
future problems. 24-hour emergency access to the unit was offered throughout the duration of outpa-
tient treatment. Sessions were delivered by psychiatrists, community psychiatric nurses, and psychi-
atric nurses (no further information on experience was reported).
Comparator: TAU. For around one quarter (n = 34) this involved admission to an inpatient unit, whilst
for the remaining three-quarters (n = 100), this involved referral to outpatient services.
Length of treatment: unclear.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report, hospital records, or both.
Secondary outcome(s): i) hopelessness measured by the BHS; ii) general symptoms measured by the
SCL-90; iii) service use ascertained from self-report; iv) suicide (unclear how ascertained).
Notes Source(s) of funding: “This study was supported by grant OG 92-023 of the National Health Insurance
Council (Ziekenfonds-Raad)” (Van der Sande 1997, p. 40).
Van Heeringen 1995

Methods Participants were individually randomised using an open randomisation list to either case manage-
ment or TAU.
N lost to follow-up: 125/516 (24%) for repetition of SH data by the 12-month assessment.
Location: Ghent, Belgium.
Participants Number of total participants: 516 participants were randomised, 258 were allocated to a compliance
enhancement intervention, and 258 were allocated to TAU.

Informed decisions.
Van Heeringen 1995 (Continued)

Profile of participants: mean (SD) age not reported (range not reported). Just under half (n = 222; 43.0%)
were female. Just under one third (n = 155; 30.0%) had a history of SH (i.e. multiple episodes of SH). A
minority (n = 77; 14.9%) were diagnosed with any mood disorder, followed by any anxiety disorder (n =
14; 2.7%).
Source of participants: patients treated in an A&E department following a suicide attempt.
Inclusion criteria: i) aged 15 years of age or older; ii) lived in the catchment area.
Exclusion criteria: i) currently receiving inpatient medical treatment.
Interventions Intervention: case management and compliance enhancement involving home visits (number and du-
ration not reported) to those participants who did not keep to scheduled outpatient appointments in
addition to TAU. Therapeutic content involved discussing reasons for not attending appointments and
the patient was encouraged to attend future treatment sessions. Sessions were delivered by communi-
ty nurses (no further information on experience was reported).
Comparator: TAU consisting of outpatient appointments only (number and duration not reported).
Non-compliant participants did not receive home visits.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report supplemented by collateral report
from GPs, relatives, or both; ii) treatment adherence measured by the number of sessions attended; iii)
suicide (unclear how ascertained).
Notes Source(s) of funding: “This study was supported by a grant from the National Fund for Scientific Re-
search (NFWO, grant no. 3.0061.86)” (Van Heeringen 1995, p. 969).
Walton 2020
Methods Participants were individually randomised using a computer-generated sequence and a blocking pro-
cedure stratified by sex and antidepressant use at baseline, to either DBT or alternative psychotherapy.
N lost to follow-up: 48/162 (25.3%) for repetition of SH by the post-intervention assessment (data ob-
tained by correspondence).
Location: Newcastle, NSW, Australia.
allocated to alternative psychotherapy (conversational model).
Profile of participants: mean age 22.6 ± 7.8 years (range: 18-65 years). Just over three-quarters (n = 125;
77.2%) were female. All (n = 162; 100%) were diagnosed with BPD. Just over half (n = 89; 54.9%) were di-
agnosed with any anxiety disorder, followed by MDD (n = 84; 51.8%), and SUD (n = 45; 27.8%).
Source of participants: patients referred to a specialist DBT service. Correspondence with trial authors
also revealed that all had engaged in SH resulting in presentation to clinical services within six months
preceding trial entry.
Inclusion criteria: i) aged 18-65 years of age; ii) diagnosed with BPD according to DSM-IV criteria; iii) ≥ 3
episodes of suicide attempts and/or NSSI in the 12 months preceding trial entry.
Exclusion criteria: i) diagnosed with an organic disorder, psychosis, or a developmental disability; ii) en-
gaging in antisocial behaviour that posed a significant threat to staff and fellow patients; iii) lived out-

Informed decisions.
Walton 2020 (Continued)

side the catchment area; iv) insufficient language ability; v) substance dependant (other than nicotine);
vi) previously treatment with BDT or conversational psychotherapy.
Interventions Intervention: DBT consisting of 52 weekly individual therapy sessions (60 minutes) and 52 weekly
group-based skills sessions (2.5 hours). Participants also had access to telephone coaching, as re-
quired. DBT therapists also participated in weekly consultation team meetings (duration not reported).
Therapeutic content involved directive, problem-oriented techniques (including behavioural skill train-
ing, contingency management and cognitive modification) alongside supportive techniques. Sessions
were delivered by psychiatrists, psychologists, psychiatric trainees, mental health nurses, social work-
ers, or occupational therapists with a minimum of two years clinical experience and who had received
training (duration not reported) in delivering the intervention. Over one-third (37.5%) delivered both
the intervention and comparator conditions.
Comparator: manualised conversational model psychotherapy consisting of twice weekly sessions (60
minutes) based on Meares 2004. Therapeutic content was nondirective and included a focus on emo-
tional misunderstanding, mutual self-reflection, repair of the moment of disconnection in the thera-
peutic relationship, and the development of an authentic personal narrative.
Outcomes Primary outcome(s): i) frequency of SH ascertained from self-report using the SASII; ii) depression as
measured by the BDI.
Secondary outcome(s): i) BPD symptoms as measured by the Borderline Personality Disorder Severity
Index (BPDSI-IV); ii) dissociation as measured by the DES; iii) emotion regulation as measured by the
DERS; iv) interpersonal problems as measured by the IIP; v) mindfulness skills as measured by the Ken-
tucky Inventory of Mindfulness Skills (KIMS); vi) sense of self as measured by the Sense of Self Inventory
(SSI).
Notes Source(s) of funding: "No external research funding was obtained for this project. We acknowledge
the support of Hunter New England Mental Health Service and thank the Centre for Brain and Mental
Health Research (University of Newcastle) for providing a small grant specifically to cover the cost of
adherence coding" (Walton 2020, p.13).
Conflict(s) of interest: "The author(s) declared no potential conflicts of interest with respect to the re-
search, authorship and/or publication of this article" (Walton 2020, p.13).
Wang 2016
Methods Participants were individually randomised "according to the order of their documented suicide report
number received...Report numbers with an odd number were grouped into the TAU group, while even
numbered reports were grouped into the coping card group" (Wang 2016, p.108).
Location: Chia-Yi City, Taiwan.
intervention (emergency card), and 32 were allocated to TAU.
Profile of participants: mean age 37.9 ± 11.1 years (range: not reported). Almost three-quarters (n = 47;
73.4%) were female. Just over one third (n = 23; 35.9%) had a history of SH (i.e. multiple episodes of
SH). Although over half (n = 39; 60.9%) had previously received psychiatric treatment, no information
on psychiatric diagnoses was reported.
Source of participants: patients referred by gatekeepers for case management provided by a suicide
prevention service following a suicide attempt.

Informed decisions.
Wang 2016 (Continued)

Inclusion criteria: i) referred by gatekeepers for case management provided by a suicide prevention ser-
vice following a suicide attempt; ii) sufficient language ability.
Exclusion criteria: i) moved outside of the catchment area; ii) refused a follow-up visit on ≥ 3 separate
occasions; iii) admitted to hospital, another institution, and/or imprisoned for ≥ 1 month; iv) pregnant.
Interventions Intervention: remote contact intervention (crisis card). Participants received a 180 x 108 mm paper fold-
ed into a business card size small enough to fit into a wallet. The card provided contact details for a 24-
hour crisis hotline telephone number and local contact details for local medical services. Additionally,
participants received a series of six weekly "training sessions" (duration not reported) provided during
home visits. Sessions were delivered by clinical psychologists, graduate psychologists, or social work-
ers who received training (30 minutes) in delivering the intervention.
Comparator: TAU consisting of a crisis assessment, emotional support, psychological support, and re-
ferral for other resources (i.e. community-based mental health services, social welfare, and vocational
training).
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) time to SH repetition (unclear how
ascertained).
Secondary outcome(s): i) suicide risk measured by the Suicide Risk Inventory (SRI); ii) suicidal ideation
measured by the suicidal ideation subscale of the SRI; iii) hopelessness measured by the BHS; iv) gener-
al symptoms measured by the BSRS.

Waterhouse 1990
Methods Participants were individually randomised using sequentially numbered sealed envelopes to either
general hospital admission or discharge.
N lost to follow-up: 0/77 (0%) for repetition of SH data at post-intervention.
Location: York, UK.
Participants Number of total participants: 77 participants were randomised, 38 were allocated to a short-stay hospi-
tal admission, and 39 were allocated to alternative psychotherapy (discharge from hospital).
Profile of participants: mean age 30.0 years (SD not reported; range: not reported). Over half (n = 48;
62.3%) were female. Over one third (n = 28; 36.4%) had a history of SH (i.e. multiple episodes of SH).
Source of participants: patients admitted to an A&E department following an episode of SH.
Inclusion criteria: i) aged 16 years or older.
Exclusion criteria: i) had immediate medical and/or psychiatric treatment needs.
Interventions Intervention: general hospital admission excluding additional treatment or counselling. “Hospital ad-
mission consisted of little more than a bed, without further referral to other helping agencies” (Water-
house 1990, p. 238). No information on who delivered the intervention, their expertise, or their experi-
ence was reported.
Comparator: discharge from hospital.

Informed decisions.
Waterhouse 1990 (Continued)

Length of treatment: median length of admission was 17 hours.
Outcomes Primary outcome(s): i) repetition of SH ascertained from collateral informant report (GPs), hospital
records, or both; ii) social functioning as measured by the Social Behaviour Assessment Schedule; iii)
depression and anxiety (unclear how ascertained); iv) hopelessness measured by the BHS; iv) social
isolation (unclear how ascertained); v) suicidal ideation as measured by the BSSI.
Notes Source(s) of funding: no specific sources of funding were reported.

Conflict(s) of interests: “John Waterhouse was in receipt of a research grant from the Yorkshire Regional
Health Authority” (Waterhouse 1990, pg. 241).
Other: As depression data had been combined with anxiety data in this trial, this outcome could not be
included in the present review.
Wei 2013
Methods Participants were individually randomised using a computer-generated sequence to either a CBT-
based psychotherapy, a telephone intervention, or TAU.
N lost to follow-up: 67/239 (28.0%) for repetition of SH at post-intervention; 123/239 (51.5%) at the six-
month follow-up; 151/239 (63.2%) at the 12-month follow-up.
Location: Shenyang, Liaoning Province, China.
chotherapy, 80 were allocated to a telephone intervention, and 77 were allocated to TAU.
Profile of participants: mean age 32.7 ± 14.0 (range: not reported). Just over three-quarters (n = 182;
76.1%) were female. Just under half (n = 108; 45.2%) were diagnosed with any psychiatric disorder.
Source of participants: patients admitted to ED following a suicide attempt.
Inclusion criteria: i) older than 15 years; ii) admitted to ED following a suicide attempt; iii) ≥ 1 contact
person to provide collateral reports on suicidal behaviour; iv) able to understand the trial procedures;
v) able to provide written informed consent.
Interventions Intervention: there were two experimental arms in this trial: i) CBT-based psychotherapy, and ii) tele-
phone intervention. CBT-based psychotherapy consisted of 10 weekly/biweekly/monthly sessions
(45-60 minutes). The telephone intervention involved 12 psychological support calls (20-40 minutes).
Therapeutic content involved reassurance, emphatic reasoning, collaborative PST, stress management,
and encouraging participants to increase contact with existing social supports (e.g. family, friends).
Sessions were delivered by therapists (no further information on expertise) with a minimum of five
years clinical work experience.
Comparator: "[P]atients in the control group did not receive any interventions” (Wei 2013, p. 109).
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report and/or collateral informant report;
ii) depression measured by the HDRS; iii) quality of life measured by an idiosyncratic scale; iv) suicidal
ideation measured by the BSSI; v) suicide (unclear how ascertained).
Notes Source(s) of funding: “This project was part of the Small Grants Program to Improve the Quality and Im-
plementation of Suicide Research in China’ which was supported by the China Medical Board of New
York (grant number 05-813)” (Wei 2013, p. 113).

Informed decisions.
Wei 2013 (Continued)

Weinberg 2006
Methods Participants were individually randomised by asking participants to choose between two similar en-
velopes to either CBT-based psychotherapy or TAU.
N lost to follow-up: 0/30 (0%) for repetition of SH data by the six-month assessment.
Location: Boston, MA, USA.
Participants Number of total participants: 30 participants were randomised, 15 were allocated to manual assisted
Profile of participants: mean age 28.2 ± 8.2 (range: 18-40 years). All (n = 30; 100%) were female.
Source of participants: recruited from the community via advertisements in local newspapers, clinical
services at a hospital, and from individuals participating in a longitudinal study.
Inclusion criteria: i) female; ii) aged 18-40 years; iii) diagnosed with BPD; iv) history of repetitive SH with
at ≥ 1 episode during the month prior to trial entry.
Exclusion criteria: i) diagnosed with comorbid psychosis; ii) judged to be at an elevated risk of suicide;
iii) diagnosed with substance abuse; iv) history of attempted suicide (only those engaging in repetitive
SH were eligible for inclusion in this trial).
Interventions Intervention: manual assisted CBT-based psychotherapy consisting of six sessions (duration not report-
ed). Therapeutic content included evaluation of the attempt, developing crisis skills problem-solving
skills, developing cognitive techniques for emotional and negative thinking management, and relapse
prevention. The primary investigator acted as the therapist (no further information on expertise or ex-
Comparator: TAU.
Length of treatment: two months.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report using the PHI; ii) borderline symp-
toms measured by the Revised Diagnostic Interview for Borderlines; iii) suicidal ideation measured by
the Suicide Behaviors Questionnaire; iv) service use measured by the Treatment Utilization Interview;
v) suicide (unclear how ascertained).
Notes Source(s) of funding: ”This study was supported by a Young Investigator Award from the Borderline Per-
sonality Disorder Research Foundation (I.W.)“ (Weinberg 2006, p. 482).
Conflict(s) of interests: no conflict of interest reported.
Other: All participants were also simultaneously participating in additional treatment throughout the
duration of this trial.
Welu 1977
Methods Participants were individually randomised using a random numbers table to either intensive outpa-
tient treatment or TAU.
N lost to follow-up: 1/120 (0.8%) for repetition of SH data by the four-month assessment.
Informed decisions.
Welu 1977 (Continued)

Location: Pittsburgh, PA, USA.
Participants Number of total participants: 120 participants were randomised, 63 were allocated to intensive outpa-
tient treatment, and 57 were allocated to TAU.
Profile of participants: average age 29.0 years (IQR/SD not reported; range: not reported). Information
on sex not reported. Over half (n = 72; 60.0%) had a history of SH (i.e. multiple episodes of SH).
Source of participants: patients admitted to an A&E department following an episode of SH.
Inclusion criteria: i) over 16 years of age.
Exclusion criteria: i) student living in university accommodation; ii) resident in a care-giving institution
or institutionalised at the time of the index episode of SH.
Interventions Intervention: outreach programme involving a community mental health team contacting participants
immediately after discharge to arrange weekly/biweekly home visits. Sessions were delivered by nurs-
es, social workers, and community workers (further information on experience was not reported).
Comparator: TAU involving a psychiatric consultation at request of the treating physician. Participants
were also given a next day appointment for evaluation at the community mental health team centre.
Any further contact after discharge was at the participant’s request.
Length of treatment: unclear.
Outcomes Primary outcome(s): i) repetition of SH ascertained from self-report, hospital records, and/or collateral
informant report; ii) AOD use ascertained from self-report, hospital records, and/or collateral informant
report; iii) adverse events (purposive accidents) ascertained from self-report, hospital records, and/or
collateral informant report; iv) service use ascertained from records.
Notes Source(s) of funding: “This investigation was supported by Research Grant MH19491 from the National
Institute of Mental Health” (Welu 1977, p. 17).
AA: alcoholics anonymous

AAQ: Acceptance and Action Questionnaire
ACT: Acceptance and Commitment Therapy
A&E: Accident and Emergency
AOD: alcohol and other drug
ASPD: antisocial personality disorder
ASSIP: Attempted Suicide Short Intervention Program
AUD: Alcohol use disorder
AUDIT: Alcohol Use Disorders Identification Test
BAI: Beck Anxiety Inventory
BDI: Beck Depression Inventory
BEST: Brief Education Supported Treatment
BHS: Beck Hopelessness Scale
BIS: Barratt Impulsiveness Scale
BPD: borderline personality disorder
BPDSI-IV: Borderline Personality Disorder Severity Index, 4th revision
BSRS: Brief Symptom Rating Scale
BSSI: Beck Scale for Suicidal Ideation
CAMS: Collaborative Assessment and Management of Suicidality
CBT: Cognitive Behavioural Therapy
CGI: Clinical Global Impression
CIP: Cultural Impact Profile
cRCT: cluster randomised controlled trial
CSQ-8: Client Satisfaction Questionnaire (8 item)
CSRI: Client Services Receipt Inventory
DASS: Depression Anxiety Stress Scale
DBT: Dialectical Behaviour Therapy
Informed decisions.
DERS: Difficulties in Emotion Regulation Scale

DES(-T): Dissociative Experiences Scale (-Taxon)
DSHI: Deliberate Self-Harm Inventory
DSM-IV(-TR): Diagnostic and Statistical Manual for mental disorders, version IV (Text Revision)
ED: emergency department
EPSIS: European Parasuicide Study Interview Schedule
EQ-5D: European Quality of Life-5 Dimension
ESS: Experience of Shame Scale
EUC: enhanced usual care
EuroQoL: European Quality of Life
FRAMES: Feedback, Responsibility, Advice, Menu, Empathic, and Self-efficacy
GAD: Generalized Anxiety Disorder
GAF: General Assessment of Functioning
GAS: Global Assessment Scale
GHQ(-12): General Health Questionnaire (12 item)
GP: general practitioner
GSI: Global Severity Index
HADS: Hospital Anxiety and Depression Scale
HAMD-24: Hamilton Rating Scale, 24-item
HDRS: Hamilton Depression Rating Scale
HRSA: Health Resources and Services
HRSD: Hamilton Rating Scale for Depression
HSRS: Health Sickness Rating Scale
ICD-10: International Classification of Diseases, 10th Revision
IIP: Inventory of Interpersonal Problems
IQ: intelligence quotient
IQR: interquartile range
KIMS: Kentucky Inventory of Mindfulness Skills
LSASI: Lifetime Suicide Attempt Self-Injury Interview
MBT: Mentalisation-Based Therapy
MDD: Major Depressive Disorder
MEPS: Means-Ends Problem-Solving procedure
MINIM: minimisation programme
MMPI: Minnesota Multiphasic Personality Inventory
NA: narcotics anonymous
NR: not reported
NSSI: non-suicidal self-injury
PD: personality disorder
p.: page
PHI: Parasuicide History Inventory
PSS-I: PTSD Symptom Scale - Interview
PST: problem-solving therapy
PTSD: Post-traumatic stress disorder
SAPAS: Standardised Assessment of Personality - Abbreviated Scale
SAS: Social Assessment Scale
SASII: Suicide Attempt-Self-Injury Interview
SCID-II: Structured Clinical Interview for DSM-IV Axis II Personality Disorders
SCL-90: Symptom Check List-90
SD: standard deviation
SF-36: Social Functioning - 36 item
SFQ: Social Functioning Questionnaire
SH: self-harm
SHI: Self-Harm Inventory
SMART: Specific, Measurable, Achievable, Relevant, and Time-bound
SPSI: Social Problem-Solving Inventory
SRI: Suicide-Resilience Inventory
SSRI: Selective Serotonin Reuptake Inhibitor
STAXI: State-Trait Anxiety Inventory
SUD: substance use disorder
SUPRE-MISS: SUicide-PREvention Multisite Intervention Study on Suicidal behaviours
TAU: Treatment-as-usual
THI-2: Treatment History Interview-2
Informed decisions.
TRGI: Trauma-Related Guilt Interview

VHS: Volitional Help Sheet
vs.: versus
WHO: World Health Organization
ZAN-BPD: Zanarini Rating Scale for Borderline Personality Disorder
15D: 15D measure of health-related quality of life
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Agyapong 2016 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Ahmed 2016 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Albuixech-García 2020 Non-RCT
Andover 2015 Non-RCT
Andover 2017 At baseline, 78.8% of the sample had engaged in SH.
Andreasson 2016 Due to difficulties in recruitment, inclusion criteria for recency of SH was changed from within one
month of trial entry to within five years of trial entry. At baseline, 96% of the sample had engaged in
SH.
Andreoli 2019 Reported on outcomes ≥ 3 years post-intervention. Data for earlier follow-up assessments were in-
cluded in this review, however.
Barnes 2018 At baseline, 25.0% of the sample had engaged in SH.
Barnhofer 2015 Participants engaging in regular SH were excluded.
Bateman 2020 Reported on outcomes ≥ 8 years post-intervention. Data for earlier follow-up assessments were in-
cluded in this review, however.
Bentley 2017 At baseline, mean number of SH episodes per participant was < 1, suggesting that not all some par-
ticipants had engaged in SH.
Berrouiguet 2019 Study protocol. However, non-RCT
Betz 2020 Correspondence with trial authors indicated information on SH within six months of trial entry was
not recorded. However, at baseline, 6.1% of the sample had presented to the ED with SH.
Bryan 2017a At baseline, 56.0% of the sample had engaged in SH.
Bryan 2017b At baseline, 44.0% of the sample had engaged in SH.
Cebria 2015 Non-RCT
Celano 2017 Correspondence with trial authors indicated information on SH within six months of trial entry was
not recorded. However, at baseline, 41.5% had engaged in SH.
Currier 2015 Study protocol. However, non-RCT
Dassa 2018 We were unable to locate full text despite correspondence.

Informed decisions.
Davidson 2006 Information on SH within six months of trial entry was not recorded. However, at baseline, 70.7%
had engaged SH.
Dimeff 2020 Non-RCT
Di Simplicio 2020 Participants were recruited from non-clinical settings.
Dixon-Gordon 2015 Participants were recruited from non-clinical settings.
Doering 2010 At baseline, 61.5% of the sample had engaged in SH.
Ducasse 2018 We were unable to obtain data on the proportion of participants with an episode of SH within six
months of trial entry from trial authors. However, at baseline, 27.5% had engaged in SH within one
month of trial entry.
Exbrayat 2017 Non-RCT
Franklin 2016 Participants were recruited from non-clinical settings.
Gabilondo 2020 Non-RCT
Galfalvy 2017 We were unable to locate full text despite correspondence.
Gooding 2020 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Goodman 2016 We were unable to obtain data on the proportion of participants with an episode of SH within six
months of trial entry from trial authors.
Goodman 2020 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Haddock 2019 We were unable to obtain data on the proportion of participants with an episode of SH within six
Hashemi-Aliabadi 2020 Non-RCT
Hooley 2014 At baseline, 74.6% of the sample had engaged in SH.
Hooley 2018 Participants were recruited from non-clinical settings.
Hurtado-Santiago 2018 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Inder 2015 At baseline, 50.0% of the sample had engaged in SH.
ISRCTN10115835 Recruitment into this trial has suspended.
ISRCTN16003313 Trial paused. Recruitment into this trial has suspended due to COVID-19 restrictions.
ISRCTN18761534 Trial registration record last updated 12 December 2017. Current status therefore unknown
Jardon 2019 Non-RCT

Informed decisions.
Jobes 2017 At baseline, 50.0% of the sample had engaged in SH.
Johnson 2018 SH did not occur within six months of trial entry.
Kawanishi 2018 Study protocol for a cohort follow-up study of an RCT. Data from the RCT were included in this re-
view, however.
Kennedy 2018 Participants were recruited from non-clinical settings.
Kholodkov 2015 Participants were recruited from non-clinical settings.
Kim 2020 Non-RCT
Kline 2016 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Korczak 2020 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
LaCroix 2018 Correspondence with trial authors indicated that, at baseline, 86.1% of the sample had engaged in
SH.
Lahoz 2016 Reported on outcomes ≥ 5 years post-intervention.
Lin 2019 Participants were recruited from non-clinical settings.
Luxton 2014 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Mackie 2017 Non-RCT (qualitative investigation)
Marriott 2016 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Matsubara 2019 Non-RCT
McCall 2019 At baseline, 30.1% of the sample had engaged in SH.
McManama O'Brien 2018 Correspondence with trial authors indicated information on SH within six months of trial entry not
recorded. However, at baseline, 80.4% had a lifetime history of SH.
Miller 2016 At baseline, 74.5% had engaged in SH.
Morley 2014 At baseline, 55.1% had engaged in SH within six months of trial entry.
Navarro-Haro 2018 Correspondence with trial authors indicated that, at baseline, 38.9% had engaged in NSSI and
38.9% had made a suicide attempt.
NCT00218725 Correspondence with trial authors indicated the trial was terminated early due to feasibility prob-
lems in identifying and recruiting participants.
NCT00601939 Trial paused. Recruitment into this trial has suspended due to COVID-19 restrictions.
NCT00603421 We were unable to locate full text despite correspondence.
NCT00980824 Trial registration record last updated 28 June 2010. Current trial status therefore unknown

Informed decisions.
NCT01359761 Sample overlapped with LaCroix 2018.
NCT01823120 Correspondence with trial authors indicated the trial was terminated early due to a lack of funding
and resignation of critical trial staff.
NCT02227160 Trial was withdrawn due to a lack of funding.
NCT02299440 We were unable to obtain data on the proportion of participants with an episode of SH within six
NCT02522143 Trial was withdrawn due to a lack of funding.
NCT02742922 Trial registration record last updated 1 February 2018. Current trial status therefore unknown
NCT03376113 Trial registration record last updated 1 December 2018. Current trial status therefore unknown
NCT03489382 Trial registration record last updated 1 June 2018. Current trial status therefore unknown
NCT03533075 Trial registration record last updated 1 August 2019. Current trial status therefore unknown
NCT03600532 Trial terminated early due to feasibility problems in identifying and recruiting participants
NCT03943862 Trial terminated early due to feasibility problems in identifying and recruiting participants
O'Toole 2019 At baseline, 16.3% of the sample had engaged in SH.
Pearce 2017 At baseline, 66.7% of the sample had engaged in SH.
Pfeiffer 2019 At baseline, 77.1% of the same had engaged in SH.
Philips 2018 Participants were recruited from non-clinical settings.
Pistorello 2020 At baseline, 30.6% of the sample had engaged in SH.
Pratt 2015 At baseline, 85.5% of the sample had engaged in SH.
Rees 2015 Trial terminated early due to feasibility problems in identifying and recruiting participants
Rompogren 2018 Participants were recruited from non-clinical settings.
Rudd 2015 At baseline, 59.3% of the sample had engaged in SH.
Ryberg 2019 At baseline, 69.2% of the sample had engaged in SH.
Sáiz 2014 Correspondence with trial authors indicated that not all participants were randomised to the inter-
vention or control arms; some could choose to receive the intervention (i.e. non-RCT).
Santel 2020 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Sayal 2019 Trial terminated early due to to feasibility problems in identifying and recruiting participants. Addi-
tionally, at baseline, 81.8% of the sample had engaged in SH.

Informed decisions.
Sequeira 2016 At baseline, 15.4% of the sample had engaged in SH.
Simon 2016 Study protocol. However, unlikely that all participants would have engaged in SH at baseline
Sinnaeve 2018 Correspondence with trial authors indicated information on SH within six months of trial entry was
not recorded. However, at baseline, 91.7% of the sample had engaged in SH.
Slesnick 2020 At baseline, 80.0% of the sample had engaged in SH.
Smits 2020 At baseline, 42.1% had engaged in NSSI and 16.7% had made a suicide attempt.
Taha 2015 SH did not occur within six months of trial entry.
Tejedor 2011 Correspondence with trial authors indicated information in SH within six months of trial entry was
not recorded. However, at baseline, 39.0% had engaged in SH.
Vaiva 2016 Book chapter
Van Spijker 2018 At baseline, 54.3% of the sample had engaged in SH.
Ward-Ciesielski 2016 Participants were recruited from non-clinical settings.
Westling 2019 At baseline, 80.0% of the sample had engaged in SH.
Wilks 2018 Participants were recruited from non-clinical settings.
Wittouck 2014 Participants were those bereaved by suicide.
Yang 2020 Participants were recruited from non-clinical settings.
ED: emergency department; NSSI: non-suicidal self-injury; RCT: randomised controlled trial; SH: self-harm.
Characteristics of studies awaiting classification [ordered by study ID]
NCT00533117
Methods Triple (participant, investigator, outcome assessor)-blind RCT
Assignment: parallel-group, individual-level
Participants Inclusion criteria: i) aged between 18 and 55 years; ii) diagnosed with borderline personality disor-
der; iii) at least one suicide attempt in the two months preceding trial entry; iv) at least one further
suicide attempt in the year preceding trial entry; v) experiences continued SH urges; vi) stable liv-
ing situation; vii) clinically stable enough to undergo a wash-out of all psychotropic medications;
viii) not participating in other forms of treatment; ix) women of child-bearing age must also be us-
ing effective birth control
Exclusion criteria: i) diagnosed with any organic mental disorder (current); ii) lifetime diagnosis of
schizophrenia, another psychosis, bipolar disorder, or mental retardation; iii) unable and/or unwill-
ing to complete a psychiatric interview; iv) unable to tolerate DBT or fluoxetine; v) currently receiv-
ing treatment for an acute medical illness, including substance abuse or anorexia nervosa; vi) his-
tory of major depression lasting longer than three months; vii) Hamilton Depression Score > 22; viii)
pregnant or breastfeeding
Interventions Intervention 1 (DBT plus fluoxetine): DBT consisting of twice weekly individual therapy sessions (60
minutes' duration) and once weekly group therapy sessions (90 minutes' duration) for 12 months

Informed decisions.
NCT00533117 (Continued)
in addition to fluoxetine administered with a starting dose of 20 mg/day increasing by 20 mg/day in
monthly increments to one month, depending on tolerability, to up to 80 mg/day
Intervention 2 (Supportive psychotherapy plus fluoxetine): Supportive psychotherapy consisting of

weekly individual therapy sessions (50 minutes' duration) for 12 months in addition to fluoxetine
administered with a starting dose of 20 mg/day increasing by 20 mg/day in monthly increments to
one month, depending on tolerability, to up to 80 mg/day
Comparator 1 (DBT plus placebo): DBT consisting of twice weekly individual therapy sessions (60
minutes' duration) and once weekly group therapy sessions (90 minutes' duration) for 12 months in
addition to placebo
Comparator 2 (Supportive psychotherapy plus placebo): Supportive psychotherapy consisting of

weekly individual therapy sessions (50 minutes' duration) for 12 months in addition to placebo
Outcomes Primary outcome(s): i) repetition of SH as ascertained from self-report
Notes
NCT00834834
Methods Single-blind RCT
Participants Inclusion criteria: i) meets DSM-IV criteria for borderline personality disorder; ii) at least one sui-
cide attempt in the two months preceding trial entry; iii) at least one further suicide attempt in the
year preceding trial entry; iv) current suicidal ideation; v) not currently receiving optimum psychi-
atric treatment; vi) has a stable living arrangement; v) sufficient language ability; vi) clinically sta-
ble enough to undergo a washout of all psychotropic medications with the exception of benzodi-
azepines; viii) women of child-bearing age must also be using effective birth control
Exclusion criteria: i) diagnosed with an intellectual disability, bipolar disorder, schizophrenia, delu-
sional disorder; schizophreniform disorder, schizoaffective disorder, or a psychotic disorder not
otherwise specified; ii) severe psychiatric disorder or medical condition requiring acute treatment;
iii) clinically too unstable to be treated as an outpatient; iv) failed two adequate trials of fluoxetine
and citalopram within the two years preceding trial entry; v) history of severe allergies, adverse
drug reactions, or known allergy to fluoxetine or citalopram; vi) has a heart pacemaker body im-
plant, other metal implants, shrapnel or surgical prostheses that may present a risk to the partici-
pant or interfere with the fMRI scan; vii) diagnosed with Raynaud's disorder; viii) history of hyper-
tension, cardiovascular disease, or abnormal electrocardiograms; ix) claustrophobia or significant
discomfort in enclosed space; x) pregnant
Interventions Psychosocial: DBT consisting of weekly individual therapy sessions (60 minutes' duration) and
group therapy sessions (90 minutes' duration) for six months
Pharmacological: fluoxetine. Starting dose of 20 mg/day increasing to over four weeks, depending
on tolerability, to up to 40 mg/day. Treatment will last six months.
Outcomes Primary outcome(s): i) SH, as measured by the Columbia Suicide History Interview (CSHI)
Secondary outcome(s): i) number of participants with SH, as measured by the CSHI
Notes
CSHI: Columbia Suicide History Interview; DBT: dialectical behaviour therapy; DSM-IV: Diagnostic and Statistical Manual of Mental
Disorders, fourth revision; fMRI: functional magnetic resonance imaging; mg: milligram; RCT: randomised controlled trial; SH: self-harm.

Informed decisions.
Characteristics of ongoing studies [ordered by study ID]
ACTRN12617000529347
Study name Will prisoners who self-harm reduce their frequency of self-harming after going through the dialec-
tical behaviour therapy intervention?
Methods Open-label RCT
Allocation: parallel-group, blocked, individual-level
Participants Inclusion criteria: i) males; ii) between 14 and 21 years of age; iii) convicted of any offence and cur-
rently serving a term of imprisonment; iv) remaining length of sentence of six months or greater; v)
able to understand trial procedures (but not necessarily how to read or write)
Exclusion criteria: i) females; ii) insufficient language ability; iii) foreign nationality; iv) diagnosed
with a psychiatric disorder, alcohol, drug, or other physical health condition that would interfere
with participation
Interventions Intervention: group-based DBT. Twice weekly sessions (two hours' duration) of manualised, group-
based DBT for 12 weeks
Comparator. TAU, consisting of psychoeducation and ongoing monitoring by prison medical staff
Outcomes Primary outcome(s): i) SH, as measured by the Inventory of Statements about Self-Injury (ISAS); ii)
borderline personality disorder symptoms, as measured by the Structured Clinical Interview for
Borderline Personality Disorder (SCID-BPD)
Secondary outcome(s): i) well-being, as measured by the Well-being Survey; ii) emotion regulation,
as measured by the Difficulties in Emotion Regulation Scale (DERS)
Starting date 26 April, 2017
Contact information Principal investigator:
Prof. Brin Grenyer, University of Wollongong, Wollongong, New South Wales, Australia (greny-
er@uow.edu.au)
Notes We were unable to confirm the above details were correct despite correspondence.
Berrouiguet 2014
Study name SIAM (Suicide Intervention Assisted by Messages): The development of a post-acute crisis text mes-
saging outreach for suicide prevention
Assignment: parallel-group, blocked, individual-level
Participants Inclusion criteria: i) aged 18 years and older; ii) discharged from the emergency department and/or
psychiatric unit following a presentation for attempted suicide; iii) hospitalised for < 7 days; iv) able
to provide informed consent; v) able to be contacted by telephone
Exclusion criteria: i) unwilling or unable to provide informed consent; ii) under guardianship; iii) in-
carcerated; iv) enrolled in other trials; v) not in possession of a mobile (cell) telephone
Interventions Intervention: a series of nine text messages sent within 48 hours post-discharge, at days 8, 15,
and at months 1, 2, 3, 4, 5, and 6. Message content will provide validation, reminders of discharge
agreements, and will also include information on how to access support from the participants’

Informed decisions.
Berrouiguet 2014 (Continued)

managing doctor (i.e. psychiatrist or general practitioner, as appropriate), as well as appointment
reminders.
Comparator: TAU
Outcomes Primary outcome(s): i) repetition of SH as measured by the Columbia Scale
Secondary outcome(s): i) suicidal ideation as measured by the Columbia Scale; ii) satisfaction with
treatment as measured using a study-specific scale
Dr. Sofian Berrouiguet, Brest Medical University Hospital, Brest, France
(sofian.berrouiguet@gmail.com)
Notes
Chaïb 2020
Study name Group post-admission cognitive therapy for suicidality vs individual support therapy for the pre-
vention of repeat suicide attempts: a randomized controlled trial
Methods Single (assessor)-blind RCT
Participants Inclusion criteria: i) aged 18 years and older; ii) hospitalised for the prevention of suicide; iii) high
suicide risk score, as measured by the MINI; iv) suicide attempt within the month prior to trial entry;
v) available to attend mid-week appointments; vi) insured or beneficiary of a health insurance plan;
vii) sufficient language ability; viii) able to provide informed consent
Exclusion criteria: i) participated in another interventional trial within the three months prior to trial
entry; ii) under an exclusion period as a consequence of participating in another trial; iii) under ju-
dicial protection or is an adult under legal guardianship; vi) unable and/or unwilling to provide in-
formed consent; v) diagnosed with schizophrenia or another psychotic disorder according to the
MINI; vi) diagnosed with a severe cognitive impairment on clinical observation; vii) diagnosed with
a severe AOD dependence
Interventions Intervention: group-based CBT consisting of six weekly sessions (90-120 minutes' duration) over six
weeks. Therapeutic content is based on the Post-Admission Cognitive Therapy model (Ghahraman-
lou-Holloway 2012). Therapeutic content includes: i) psychoeducation; ii) problem identification;
iii) cognitive restructuring; iv) behavioural activation; v) identification of reasons for living; vi) hope
box; vii) emotion regulation; viii) development of coping strategies; ix) problem-solving; x) relapse
prevention; xi) safety planning.
Comparator: individual supportive therapy consisting of six weekly sessions (60-90 minutes' dura-
tion) over six weeks. Therapeutic content includes: i) providing a supportive, non-judgemental and
empathetic environment in which the participant can explore reasons for SH. Therapists are specif-
ically told to avoid applying any principles of CBT-based psychotherapy.
Length of treatment: six weeks
Outcomes Primary outcome(s): i) time to SH repetition (unclear how ascertained)
Secondary outcome(s): i) suicidal ideation, as measured by the C-SSRS and the BSSI; ii) depres-
sion, as measured by the BDI; iii) hopelessness, as measured by the BHS; iv) general symptoms, as

Informed decisions.
Chaïb 2020 (Continued)

measured by the MINI-7; v) suicide attempt lethality, as measured by the Risk Rescue Rating Scale
(RRRS)
Starting date 1 November, 2017
Contact information Pincipal investigator:
Dr. Laurent Chaïb, Centre Hospitalier Université de Nîmes, Nîmes, France (lauren-
t.chaib@chu-nimes.fr)
Notes
McMain 2018
Study name The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality
disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol
Methods Multisite, single (assessor)-blind RCT
Participants Inclusion criteria: i) aged between 18 and 65 years; ii) diagnosed with BPD according to DSM-IV cri-
teria and the International Personality Disorders Examination; iii) ≥ 2 episodes of SH in the five
years prior to trial entry, including ≥ 1 episode in the eight weeks prior to trial entry; iv) sufficient
language ability; v) able to provide informed consent; vi) have either Ontario Health Insurance Plan
(OHIP) coverage or BC Medical Services Plan (MSP) health insurance for ≥ 1 year
Exclusion criteria: i) received > 8 weeks of DBT in the 12 months prior to trial entry; ii) diagnosed
with psychosis, bipolar disorder, or dementia according to DSM-IV criteria; iii) estimated IQ ≤ 70; iv)
diagnosed with a chronic physical health condition expected to require periods of hospitalisation
within the next 12 months (e.g. cancer); v) plan to move outside of the catchment area within the
next two years
Interventions Intervention 1: manualised DBT (12-month protocol) consisting of weekly sessions (one hour) of in-
dividual therapy, weekly sessions (2 hours) of group skills training, access to 24/7 telephone con-
sultation, as needed, and weekly (duration not reported) therapist consultation meetings. Thera-
peutic content involves: i) acceptance-based techniques; ii) problem-solving; iii) behavioural analy-
sis; iv) contingency management; v) skills training.
Intervention 2: manualised DBT (six-month protocol) consisting of weekly sessions (one hour) of in-
dividual therapy, weekly sessions (2 hours) of group skills training, access to 24/7 telephone con-
sultation as needed, and weekly (duration not reported) therapist consultation meetings. Thera-
peutic content involves: i) acceptance-based techniques; ii) problem-solving; iii) behavioural analy-
sis; iv) contingency management; v) skills training.
Outcomes Primary outcome(s): i) frequency of SH, as measured by the SASII; ii) severity of SH, as measured by
the SASII
Secondary outcome(s): i) characteristics of SH, as measured by the L-SASI; ii) service use, as mea-
sured by the Treatment History Interview, version 2; iii) borderline symptoms, as measured by the
Borderline Symptom List-23; iv) impulsivity, as measured by the Barratt Impulsiveness Scale-11; v)
depression, as measured by the BDI; anger, as measured by the State-Trait Anger Expression Inven-
tory-2; vi) general symptomatology, as measured by the Symptom Checklist-90 Revised; vii) inter-
personal functioning, as measured by the Inventory of Interpersonal Problems-64; viii) social func-
tioning, as measured by the Social Adjustment Scale Self-Report; ix) health-related quality of life,
as measured by the EQ-5D-5L and the SF-36; x) alcohol use, as measured by the AUDIT; xi) drug use,
as measured by the Drug Abuse Screening Test; xii) NSSI, as measured by the Inventory of State-
ments About Self-Injury; xiii) suicidal ideation, as measured by the BSSI; xiv) post-traumatic symp-

Informed decisions.

toms, as measured by the PTSD Checklist for DSM-5; xv) emotion regulation, as measured by the
DERS; xvi) mindfulness, as measured by the Kentucky Inventory of Mindfulness; xvii) coping during
stressful situations, as measured by the Dialectical Behavior Therapy-Ways of Coping Checklist
Tertiary outcome(s): i) personality, as measured by the NEO-Five Factor Inventory; ii) experiences of
trauma, as measured by the Childhood Trauma Questionnaire-Short Form and the Credibility/Ex-
pectancy Questionnaire; iii) therapeutic alliance, as measured by the Working Alliance Invento-
ry-Short Form (therapist and client versions); iv) reasons for treatment discontinuation, as mea-
sured by the Reasons for Early Termination from Treatment Questionnaire
Starting date 1 February 2015
Dr. Shelley McMain, Centre for Addiction and Mental Health, Department of Psychiatry, University
of Toronto, Toronto, Canada (shelley.mcmain@camh.ca)
Notes
NCT02060448
Study name Exploring two emotion-focused treatment modules in non-suicidal self-injury
Methods Single-case experimental design. Participants are randomly allocated to receive either mindful
emotion awareness training or cognitive reappraisal and then, depending on improvement, are
permitted to cross over to receive the alternate module.
Participants Inclusion criteria: i) aged 18 years and older; ii) current NSSI; iii) meets DSM-5 criteria for NSSI; iv) ei-
ther not taking psychotropic medications, or taking stable doses likely to be maintained through-
out the duration of the trial
Exclusion criteria: i) current suicidal ideation with a plan; ii) currently receiving CBT or any other
psychotherapy to reduce NSSI, anxiety, depression, or other Axis I disorder; iii) unwilling to refrain
from initiating additional treatment throughout the duration of the trial; iv) current or recent (with-
in three months) history of a substance use disorder; v) experiencing emotional symptoms due to a
medical/physical condition
Interventions Intervention (mindful emotion awareness training): consisting of four 50-minute weekly sessions of
mindful emotion awareness training
Intervention (cognitive reappraisal): consisting of four 50-minute weekly sessions of cognitive reap-
praisal
Outcomes Primary outcome(s): i) frequency of urges and acts of NSSI, as ascertained from self-report
Secondary outcome(s): i) anxiety, as measured by the OASIS and BAI; ii) depression as measured
by the ODSIS and BDI; iii) emotion regulation, as measured by the Deficits in Emotion Regulation
Scale (DERS) and the Emotion Regulation Questionnaire (ERQ); iv) mindfulness, as measured by
the Southampton Mindfulness Questionnaire (SMQ); v) experiential avoidance, as measured by the
Multi-dimensional Experiential Avoidance Questionnaire (MEAQ); vi) sleep problems, as measured
by the Insomnia Severity Index (ISI); vii) subjective symptomatology, as measured by the Subjec-
tive Symptoms Scale (SSS)
Tertiary outcome(s): i) self-injury implicit associations, as measured by the Self-Injury Implicit Asso-
ciation Test (SI-IAT)
Starting date 1 November, 2013

Informed decisions.
End date: 31 December, 2015
Contact information Principal investigators:
Prof. David Barlow, Boston University, Boston, MA, USA (dhbarlow@bu.edu)
Assistant Prof. Kate Bentley, Harvard Medical School, Harvard University, Cambridge, MA, USA
(KBENTLEY@mgh.harvard.edu)
Notes We are grateful to Assistant Prof. Kate Bentley for confirming the above details were correct, 21 Oc-
tober, 2020.
NCT02354183
Study name Commitment and motivation in a brief DBT intervention for self harm
Participants Inclusion criteria: i) aged between 18 and 80 years; ii) ≥ 3 episodes of SH in the five year preceding
trial entry, including ≥ 1 in the preceding eight weeks; iii) received no more than four weeks of DBT
in the one year preceding trial entry; iv) self-reports no knowledge of core DBT skills; v) has a valid
Canadian healthcare card; vi) sufficient language ability
Exclusion criteria: i) diagnosed with an organic brain disorder and/or intellectual disability
Interventions Intervention: DBT. Single one-hour session of DBT core skills, including wise mind, distraction,
mindfulness of the current emotion, and opposite to emotion action skills, in addition to psychoed-
ucation
Comparator: Psychoeducation. Single one-hour session of psychoeducation
Outcomes Primary outcome(s): i) motivation, as measured by the Autonomous and Controlled Motivation for
Treatment Questionnaire
Secondary outcome(s): i) frequency of SH, as measured by the DSHI; ii) severity of SH, as measured
by the DSHI
Dr Michelle Leybman, McGill University, Montreal, Quebec, Canada (Michelle.leybman@mail.m-

cgill.ca)
NCT03081078
Study name Effects of community-based caring contact on post-discharge young adults with self-harm - a mul-
ti-center randomized controlled trial

Informed decisions.
Participants Inclusion criteria: i) aged between 18 and 45 years; ii) ≥ 1 episode of SH, ascertained from ICD-10 as-
signed codes, leading to admission to the ED; iii) received mental health assessment by a psychia-
trist or consultation liaison nurse; iv) able to provide written informed consent
Exclusion criteria: i) diagnosis of any DSM-IV-TR axis II personality disorder; iii) diagnosed with psy-
chosis or bipolar disorder
Interventions Intervention 1: Mobile (cell) telephone app with remote contact intervention in addition to TAU.
Participants receive access to the app (no further details on content or therapeutic focus provided)
and remote contact (≥ 2 telephone contacts and/or text messages) by volunteers over a two-month
period in addition to TAU.
Intervention 2: Mobile (cell) telephone app in addition to TAU. Participants receive access to the app
(no further details on content or therapeutic focus provided) in addition to TAU.
Control: TAU
Outcomes Primary outcome(s): i) suicidal ideation, as measured by the Chinese language translation of the
ASIQ; ii) hopelessness, as measured by the Chinese language translation of the BHS-4; iii) thwarted
belongingness, as measured by the Thwarted Belongingness subscale of the Interpersonal Needs
Questionnaire (INQ-15); iv) perceived burdensomeness as measured by the Perceived Burden-
someness subscale of the INQ-15; v) service use, as measured by the self-reported compliance with
any prescribed treatment(s); vi) SH, as measured by a four-item scale for levels of suicidality devel-
oped by the authors
Secondary outcome(s): i) depression, as measured by the Center for Epidemiologic Studies Depres-
sion Scale (CES-D); ii) frequency of SH, according to self-report and medical records; iii) suicide, as
verified by records retrieved from the Hong Kong Special Administrative Region (HKSAR) Coroner's
Court; iv) time spent engaging with the mobile app, as measured by time-stamp logs; v) time spent
engaging with remote contacts, as measured by time-stamp logs and volunteer service records
Starting date 1 June 2017
Associate Prof. Yik-Wa Law, The Univesrity of Hong Kong, Hong Kong (flawhk@hku.hk)
NCT03185026
Study name Effectiveness of the first French psychoeducational program for suicidal behavior: a randomized
controlled trial
Participants Inclusion criteria: i) aged between 18 and 65 years; ii) diagnosed with suicidal behaviour disorder
(DSM-5) (i.e. ≥ 1 suicide attempt in 12 months preceding trial entry); iii) sufficient language ability;
iv) able to provide written informed consent; iv) belongs to a social safety system
Exclusion criteria: i) current or past diagnosis of an organic mental disorder; ii) lifetime history of
schizophrenia; iii) diagnosed with an intellectual disability; iv) unable to comply with the study visit
procedures

Informed decisions.
Interventions Intervention: relaxation training consisting of 10 weekly sessions (two hours' duration) of a stan-
dardised relaxation programme
Comparator: psychoeducation consisting of 10 weekly sessions (two hours' duration) of a psychoe-

ducation programme focused on providing education on suicidal behaviour, identification of pat-
terns, and self-assessment of suicidal ideation, and presentation of a stress-diathesis model of sui-
cidal behaviour
Outcomes Primary outcome(s): i) SH, as measured by the C-SSRS
Secondary outcomes(s): i) suicide attempt (both interrupted and aborted) rate reduction, as mea-
sured by the C-SSRS; ii) suicidal ideation, as measured by the C-SSRS; iii) intensity of suicidal
ideation, as measured by the C-SSRS; iv) treatment adherence, as measured by the Medication Ad-
herence Rating Scale; v) service use, as measured by an idiosyncratic scale; vi) depression, as mea-
sured by the Inventory of Depressive Symptomatology; vii) anxiety, as measured using the State-
Trait Anxiety Inventory; viii) psychological pain, as measured by an idiosyncratic scale; ix) hopeless-
ness, as measured by the BHS; x) general functioning, as measured by the Functioning Assessment
Short Test; xi) quality of life, as measured by the World Health Organization Quality Of Life measure
(WHOQOL-BREF); xii) social support, as measured by an idiosyncratic scale; xiii) emergency service
use; xiv) acceptance, as measured by the Acceptance and Action questionnaire; xv) mindfulness, as
measured by the Mindful Attention Awareness Scale; xvi) meaning in life, as measured by the Life
Regard Index; xvii) treatment adherence, as measured by the number of sessions attended
Starting date 6 September, 2017
Dr. Deborah Ducasse, University Hospital, Montpellier, France (d-ducasse@chu-montpellier.fr)
Notes We are grateful to Dr. Deborah Ducasse for confirming the above details were correct, 28 October,
2020.
NCT03427190
Study name Suicide prevention algorithm in the French Overseas Territories (APSOM)
Methods Open-label, RCT
Participants Inclusion criteria: i) aged 16 years and older; ii) discharged from hospital within 15 days of an index
suicide attempt; iii) has healthcare insurance; iv) able to be contacted via telephone and mail; v)
resident of one of the French overseas territories participating in the trial (i.e. Guadeloupe, French
Guyana, Martinique, or Reunion Island); vi) sufficient language ability; vii) willing and able to pro-
vide oral informed consent
Exclusion criteria: i) homeless; ii) disabled, under judicial/court protection, and/or legally incompe-
tent; iii) unable to understand the study protocol
Interventions Intervention: remote contact intervention (telephone contact and/or postcards), in addition to GP
management. Participants will receive telephone contact within 21 days' post-discharge. If par-
ticipants are unable to be contacted via telephone, postcards will be sent at months' 2, 3, 4, and
5 post-discharge. Participants will also be contacted by their GP within 21 days' post-discharge to
organise a consultation within 21 to 45 days' post-discharge. Two additional GP contacts will be
made at months 6 and 13 post-discharge.

Informed decisions.
Comparator: remote contact intervention (telephone contact and/or postcards) consisting of tele-
phone contact within 21 days' post-discharge. If participants are unable to be contacted via tele-
phone, postcards will be sent at months' 2, 3, 4, and 5 post-discharge.
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) suicide (unclear how ascer-
tained)
Secondary outcome(s): i) frequency of SH repetition (unclear how ascertained); ii) anxiety and de-
pression as measured by the HADS; iii) suicide risk as measured by the C-SSRS
Starting date 9 February, 2018
Dr. Louis Jehel, University Hospital Martinique, Fort-de-France, Martinique (louis.jehel@chu-mar-

tinique.fr)
NCT03463980
Study name Compassion meditation and ReliefLink app for suicidal, low-income, African-Americans
Participants Inclusion criteria: i) aged between 18 and 64 years; ii) self-identifies as black or African-American;
iii) presents to the medical or psychiatric department of a general hospital following a suicide at-
tempt; iv) at least moderate suicidal intent, as defined by a BSSI score of ≥ 8; v) Mini Mental Status
Examination (MMSE) score ≥ 22
Exclusion criteria: i) significant cognitive impairment, as defined by a MMSE score < 22; ii) psychosis
symptoms; iii) diagnosed with an imminently life-threatening medical condition
Interventions Intervention: compassion meditation consisting of six weekly sessions (120 minutes' duration) of
compassion meditation. Participants will also be encouraged to meditate at least 30 minutes a day
and will be asked to track their daily meditation time.
Comparator: supportive group therapy consisting of six weekly sessions (90 minutes' duration) of
supportive group therapy
Outcomes Primary outcome(s): i) suicidal ideation, as measured by the BSSI
Secondary outcome(s): i) depression, as measured by the BDI; ii) shame, as measured by the Expe-
rience of Shame Scale (ESS); iii) self-criticism, as measured by the Self-Criticism Scale; iv) interper-
sonal connectedness, as measured by the Social Support Behaviors Scale (SSB); v) self-compas-
sion, as measured by the Self-Compassion Scale (SCS); vi) mindfulness, as measured by the Five
Facet Mindfulness Questionnaire (FFMQ); vii) behavioural monitoring, as measured by the Behavior
Monitoring Form (BMF)
Starting date 13 May, 2010
Prof. Nadine Kaslow, Emory University, Atlanta, GA, USA (nkaslow@emory.edu)

Informed decisions.
NCT03541824
Study name Reducing suicide risk associated with weight loss
Allocation: cross-over, individual-level
Participants Inclusion criteria: i) aged between 18 and 65 years; ii) males and females; iii) ≥ 1 episode of NSSI
within the one month prior to trial entry; iv) > 5 pounds weight suppression
Exclusion criteria: i) indicating being "sure" of suicide attempt on a trial-specific screening ques-
tionnaire; ii) lives outside of the USA; iii) pregnant
Interventions Intervention: Body Acceptance Program (BAP), an internet-based intervention designed to chal-
lenge the appearance-ideal
Comparator: waiting-list control
Outcomes Primary outcome(s): i) frequency of SH, as measured by the Self-Injurious Thoughts and Behaviors
Interview-Short Form
Secondary outcome(s): i) body self-esteem, as measured by the appearance subscale of the Body
Esteem Scale; iii) body weight esteem, as measured by the weight subscale of the Body Esteem
Scale; iv) body attribution, as measured by the attribution subscale of the Body Esteem Scale; v)
body shape, as measured by the Body Shape Questionnaire-8; vi) depression, as measured by the
BDI; vii) positive and negative affect, as measured by the Positive and Negative Affect Schedule
Starting date 1 July 2016
Prof. Pamela Keel, Florida State University, Tallahassee, FL, USA (keel@psy.fsu.edu)
Notes We are grateful to Prof. Pamela Keel for confirming the above details were correct, 29 October,
2020.
NCT03732300
Study name Evaluation of ASSIP - Attempted Suicide Short Intervention Program: a randomized controlled trial
Participants Inclusion criteria: i) aged 18 years and older; ii) suicide attempt in the six months preceding trial en-
try; iii) able and willing to provide written informed consent; iv) received treatment in an in/outpa-
tient psychiatric facility; v) able and willing to comply with the trial procedures
Exclusion criteria: i) acute psychosis; ii) insufficient language ability; iii) diagnosed with dementia;
iv) engaging in chronic SH without suicidal intent; v) receiving current ECT; vi) previously enrolled
in the trial; vii) study investigators, their family members and other dependants, and employees
are also excluded from participation
Interventions Intervention: Attempted Suicide Short Intervention Program (ASSIP) in addition to TAU. Three ses-
sions (duration not reported) of ASSIP, in addition to up to 12 remote contact interventions (letters)

Informed decisions.
Comparator: TAU
Outcomes Primary outcome(s): i) suicide deaths (unclear how ascertained); ii) repetition of SH (unclear how
ascertained); iii) duration of hospital admissions (days) ascertained from records; iv) costs of hos-
pital admissions ascertained from records; v) electrophysiological wakefulness regulation, as mea-
sured by a standardised algorithm; vi) electrophysiological heart rate variability, as measured by a
standardised algorithm
Starting date 1 December 2018
Prof. Sebastian Olbrich, University of Zurich, Zurich, Switzerland (sebastian.olbrich@puk.zh.ch)
Notes We are grateful to Prof. Sebastian Olbrich for confirming the above details were correct, 8 October,
2020.
NCT03853382
Study name Cognitive Analytic Therapy-informed Containment for self-Harm (CATCH)
Methods RCT (feasibility)
Participants Inclusion criteria: i) aged 16 years and older; ii) access to email and Internet (necessary for complet-
ing study measures); iii) currently in receipt of clinical support from National Health Service (NHS)
or private health services; iv) ≥ 5 or more episodes of NSSI in the year preceding trial entry; v) able
to provide written informed consent in English; vi) capable of providing written informed consent
Exclusion criteria: i) currently receiving any form of psychological therapy; ii) received any form of
psychological therapy in the month preceding trial entry; iii) previously received Cognitive Analytic
Therapy; iv) diagnosed with a learning disability and/or autistic spectrum disorder; v) currently at
high risk of suicidal behaviour; vi) hospitalised for SH in the one month preceding trial entry
Interventions Intervention: brief Cognitive Analytic Therapy-informed Containment for self-Harm (CATCH) con-
sisting of two sessions, each lasting approximately 90 minutes
Comparator: TAU. No further details provided
Outcomes Primary outcome(s): i) acceptability, as measured by the proportion of participants who complete
both sessions and from qualitative interviews with participants; ii) safety, as measured by the Ad-
verse Effects in Psychotherapy; iii) feasibility, as measured by the proportion of participants at-
tending a post-therapy follow-up assessment
Secondary outcome(s): i) NSSI, as measured by the Self-Injurious Thoughts and Behaviors Invento-
ry Short-Form; ii) self-compassion, as measured by the Self-Compassion Scale; iii) depression, as
measured by the PHQ-9; iv) self-injury urges, as measured by the Alexian Brothers Urges to Self-In-
jury Scale. Assessments for secondary outcomes were not completed at comparable time points
for the two arms.
Contact information Prinicpal investigator:
Dr Peter Taylor, University of Manchester, Manchester, UK (peter.taylor-2@manchester.ac.uk)
Notes We are grateful to Dr. Peter Taylor for confirming the above details were correct, 9 October, 2020.

Informed decisions.
NCT03894462
Study name Effectiveness of a targeted brief intervention for recent suicide attempt survivors
Assignment: parallel-group, individual-level (N = 400)
Participants Inclusion criteria: i) aged 18 years and older; ii) attempted suicide in the 60 days preceding trial en-
try; iii) able and willing to provide written informed consent; iv) have at least one contact person
who can promote participant’s safety and who can be contacted in the event of missed follow-up
appointments
Exclusion criteria: i) acute psychosis; ii) insufficient language ability
Interventions Intervention: Attempted Suicide Short Intervention Program (ASSIP) in addition to TAU. Three out-
patient sessions (approximately one hours' duration each) of ASSIP. All three ASSIP sessions will be
completed within six weeks. Participants have the choice to receive the intervention in person or
via telehealth.
Comparator: TAU from providers that have adopted the Zero Suicide model, incorporating en-
hanced clinical care protocols, improved clinical coding for suicidal behaviour, and the adoption of
common protocols
Outcomes Primary outcome(s): i) time to SH, as ascertained from the C-SSRS and electronic medical records
Starting date 1 October 2020
A/Prof. Anthony R. Pisani, PhD, University of Rochester Medical Center, Rochester, NY, USA (antho-
ny_pisani@urmc.rochester.edu)
Notes We are grateful to Caroline Kelberman for confirming the above details were correct, 8 October,
2020.
NCT04072666
Study name Investigations of psychological interventions in suicide prevention: a comparison of brief cognitive
behavioural therapy and the attempted suicide short intervention program
Methods Double-blind RCT
Assignment: parallel=group, block randomisation, individual-level
Participants Inclusion criteria: i) aged 16 years and older; ii) presenting to a general hospital following a recent
(duration not reported) suicide attempt; iii) referred to the Suicide Prevention Pathway
Exclusion criteria: i) unable or unwilling to provide consent; ii) receiving any other psychosocial in-
tervention. Those taking stable doses of any psychotropic medications will not be excluded.
Interventions Intervention 1: Attempted Suicide Short Intervention Program (ASSIP) plus Suicide Prevention
Pathway (SPP) consisting of three sessions (60 minutes' duration each) manualised ASSIP along
with a remote contact intervention over a 24-month period plus SPP
Intervention 2: CBT plus SPP. Five sessions (60 minutes' duration each) of manualised individ-
ual-level CBT plus SPP

Informed decisions.
Comparator: SPP. Seven sessions (duration not reported) of a blended face-to-face and online pro-
gramme incorporating a psychosocial assessment, formulation of suicide risk, collaborative safe-
ty planning, counselling on access to lethal means, development of a transition care plan, and a re-
mote contact intervention (letters and/or text messages) for a 24-month period
Outcomes Primary outcome(s): i) SH, as ascertained from representations to hospital; ii) suicide, as ascer-
tained from official records
Secondary outcome(s): i) coping, as measured by the Coping Inventory for Stressful Situations
(CISS); ii) resilience, as measured by the Resilience Scale for Adults (RSA) or the Resilience Scale for
Adolescents (READ) (as appropriate for age); iii) therapeutic alliance, as measured by the revised
Helping Alliance Questionnaire – II; iv) interpersonal problem-solving, as measured by the Indepen-
dent-Interdependent Problem Solving Scale (IIPSS)
Prof. Chris Stapelberg, Bond University, Gold Coast, Queensland, Australia (chris.stapel-
berg@health.qld.gov.au)
NCT04168645
Study name Inpatient cognitive-behavioral therapy to reduce suicide risk post-discharge
Assignment: parallel=group, stratified block randomisation, individual-level
Participants Inclusion criteria: i) aged between 18 and 65 years; ii) at least one suicide attempt in the week pre-
ceding trial entry; iii) admitted to either a medical or psychiatric inpatient ward
Exclusion criteria: i) diagnosed with a schizophrenia spectrum disorder; ii) diagnosed with an or-
ganic brain disorder and/or intellectual disability; iii) acute mania; iv) diagnosed with any other
psychiatric and/or medical condition that would preclude the participant being able to provide in-
formed consent; v) referred for ECT
Interventions Intervention: CBT. Up to four sessions of CBT (between 1 to 1.5 hours' duration)
Comparator: TAU
Outcomes Primary outcome(s): i) SH, as measured by the C-SSRS; ii) suicidal ideation, as measured by the C-
SSRS; iii) number of readmissions, as ascertained from electronic medical records
Prof. David Tolin, Yale University, New Haven, CT, USA (David.Tolin@hhchealth.org)
Notes We are grateful to Prof. David Tolin for confirming the above details were correct, 7 October, 2020.

Informed decisions.
NCT04191122
Study name Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS): a feasibility
study
Methods Double-blind RCT
Participants Inclusion criteria: i) aged 16 years and older; ii) ≥ 1 episode of SH in the six months preceding trial
entry; iii) presented to GPs
Exclusion criteria: i) diagnosed with an intellectual disability; ii) alcohol and/or drug dependant; iii)
severe suicidal ideation; iv) currently experiencing symptoms of psychosis or treatment-resistant
depression; iv) unwilling or unable to provide written informed consent; v) insufficient language
ability
Interventions Intervention: Psychodynamic psychotherapy consisting of five sessions (50 minutes' duration each)
of psychotherapy based on a psychodynamic and cognitive analytic approach in addition to TAU
Comparator: TAU based on NICE 2011 principles
Outcomes Primary outcome(s): i) treatment acceptability, as measured by the proportion of participants com-
pleting treatment; ii) adverse events, as measured by the AEP; iii) feasibility, as measured by the
number of assessments completed by participants
Secondary outcome(s): i) depression, as measured by the BDI; ii) frequency of NSSI, as measured
by the Self-Injurious Thoughts and Behaviors Interview (SITBI); iii) severity of NSSI, as measured by
the SITBI; iv) intensity of SH urges, as measured by the SITBI; v) emotion regulation, as measured
by the Emotion Regulation Questionnaire (ERQ); vi) clinical outcomes, as measured by the Clinical
Outcomes in Routine Evaluation (CORE-10); vii) help-seeking attitudes, as measured by the General
Help-Seeking Questionnaire (GHSQ) and the Actual Help Seeking Questionnaire (AHSQ); viii) thera-
peutic alliance, as measured by the Helping Relationship Questionnaire (HRQ)
Starting date 2 May 2020
Dr Pooja Saini, Liverpool John Moores University, Liverpool, UK (poojasaini@hotmail.co.uk)
NCT04244786
Study name Treating self injurious behavior: a novel brain stimulation approach
Methods Quadruple-blind RCT
Participants Inclusion criteria: i) aged between 18 and 60 years; ii) engages in frequent NSSI (defined as ≥ 2
episodes of NSSI in the two months prior to trial entry); iii) able to provide informed consent; iv) if
diagnosed with bipolar I or II disorder, taking a stable therapeutic dose of a mood stabiliser
Exclusion criteria: i) diagnosed with an unstable medical condition; ii) diagnosed with psychosis,
mania, hypomania, or an intellectual disability; iii) current suicidal ideation with a plan that can-
not be managed safely in an outpatient setting; iv) pregnant, lactating, or planning to conceive dur-
ing the trial duration; v) diagnosed with a neurological disease or prior head trauma with evidence
of cognitive impairment (defined as scoring ≥ 1.5 standard deviations below the mean on the Trail-
making A&B Test); vi) current moderate to severe alcohol or substance use disorder; v) those whose

Informed decisions.
dose of any current psychiatric medications (including antidepressants, anxiolytics, antipsychotic
medications, mood stabilisers, and benzodiazepines) was increased within two weeks prior to tri-
al entry; vi) received any form of psychotherapy within two weeks prior to trial entry; vii) any met-
al implants or paramagnetic objects contained within the body (including heart pacemaker, shrap-
nel, or surgical prostheses) which may present a risk to the participant and/or interfere with the
MRI scan; viii) claustrophobia significant enough to interfere with MRI scanning; ix) weight that ex-
ceeds 325 pounds or inability to fit into MRI scanner
Interventions Intervention: Transcranial magnetic stimulation. Six 20-minute sessions of transcranial direct cur-
rent stimulation (1.5 milliamp) delivered to the right ventrolateral prefrontal cortex
Comparator: Sham. Six 20-minute sessions where an electrode montage is applied to the right ven-
trolateral prefrontal cortex
Outcomes Primary outcome(s): i) adverse effects, as measured by the Transcranial Direct Current Stimulation
Adverse Effects Questionnaire; ii) social processing, as measured by changes in brain responses
whilst undertaking a social processing task during an fMRI scan; iii) NSSI urges and behaviours, as
measured by ecological momentary assessment (EMA)
Secondary outcome(s): i) mood state, as measured by a task during an fMRI scan and EMA
Dr Jeffrey M. Miller, New York State Psychiatric Institute and Columbia University, NYC, NY, USA
Public contact:
Young Cho, New York State Psychiatric Institute and Columbia University, NYC, NY, USA (mailto:y-
oung.cho%40nyspi.columbia.edu?subject=NCT04244786,%20#7170, Treating Self Injurious Behav-
ior: A Novel Brain Stimulation Approach)
NCT04284085
Study name Evaluation of a psychoeducational intervention for people with suicidal behaviour in the peniten-
tiary environment: N'VIU project
Participants Inclusion criteria: i) aged 18 years and older; ii) history of attempted suicide (unclear the time frame
over which this will be assessed)
Exclusion criteria: i) diagnosis of any psychiatric disorder in an acute phase; ii) intellectual disabili-
ty; iii) cognitive impairment
Interventions Intervention: psychoeducation consisting of 13 sessions (90 minutes' each), of a group-based psy-
choeducation programme
Comparator: fact-sheet on the risks of suicide, along with tips for reducing suicidal ideation
Outcomes Primary outcome(s): i) frequency of SH (unclear how ascertained)

Informed decisions.
Secondary outcome(s): i) suicidal ideation, as measured by the C-SSRS; ii) anxiety, as measured by
the HARS; iii) depression, as measured by the HDRS; iv) quality of life, as measured by the Euro-
QoL-5D Health Questionnaire
Dr. Pere Roura-Poch, Consorci Hospitalari de Vic, Barcelona, Spain (tac.vhc@aruorp)
NCT04343703
Study name Suicide prevention and intervention (SURVIVE): cohort study and nested randomized controlled tri-
als of secondary prevention programs for suicide attempts
Participants Inclusion criteria: i) aged 12 years and older; ii) presented to an ED following a suicide attempt; iii)
willing and able to provide written informed consent, and able to comply with the trial procedures
Exclusion criteria: i) unable to provide written informed consent; ii) insufficient language ability; iii)
currently participating in another clinical trial of psychosocial therapy for SH
Interventions Intervention 1: telephone management consisting of three telephone consultations (between 5-45
minutes' duration each). Therapeutic content includes: 1) assessment; 2) crisis management.
Intervention 2: internet-based CBT. Participants will receive access to an internet-based CBT pro-
gramme consisting of seven modules. Whilst the intervention can be self-paced, each module
should be worked through over a week-long period. Therapeutic content includes: i) behaviour-
al activation; ii) cognitive restructuring; iii) sleep regulation; iv) mood monitoring; v) establishing
healthy lifestyle habits.
Comparator: TAU, consisting of any nonspecific intervention to address suicidal behavior or to pre-
vent suicide
Outcomes Primary outcome(s): i) SH (unclear how ascertained); ii) suicide (unclear how ascertained)
Secondary outcomes(s): i) general symptoms, as measured by the BSI; ii) depression, as measured
by the PHQ-9; iii) anxiety, as measured by the GAD-7; iv) quality of life, as measured by the EQ-5D;
v) impulsivity, as measured by the BIS; vi) acquired capability, as measured by the Acquired Capa-
bility for Suicide Scale-Fearlessness about Death (ACSS-FAD); vii) mentalising skills, as measured by
the Reflective Functioning Questionnaire-8; viii) suicidal ideation, as measured by the C-SSRS; ix)
strengths and difficulties, as measured by the SDQ
Starting date 17 June 2020
Dr. Victor Pérez, Parc de Salut Mar, Barcelona, Spain (vperezsola@parcdesalutmar.cat)

Informed decisions.
NCT04366466
Study name Program to promote Engagement in care for the Prevention of Suicidal recidivism (PEPS)
Participants Inclusion criteria: i) aged 18 years and older; ii) admitted to a general hospital following a suicide
attempt; iii) referred for outpatient follow-up; iv) able and willing to provide written informed con-
sent
Exclusion criteria: i) not in receipt of social security and/or state medical care; ii) diagnosed with
cognitive or delusional disorders; iii) hospitalised for > 72 hours following the index suicide at-
tempt; iv) currently under psychiatric care; v) unable to be reached by telephone (e.g. without a
telephone, homeless, or incarcerated); vi) insufficient language ability
Interventions Intervention: consisting of a series of telephone contacts (both the number and duration not re-
ported) delivered over a 12-month period. Therapeutic content not reported
Comparator: TAU
Outcomes Primary outcome(s): i) repetition of SH (unclear how ascertained); ii) feasibility, as measured by the
percentage of participants fulfilling the inclusion and exclusion criteria and the proportion of par-
ticipants who received the treatment in full
Dr Fayçal Mouaffak, Centre Hospitalier de Ville-Evrard, Paris, France (mouaffakf@yahoo.fr)
NCT04420546
Study name Using implementation intentions to reduce self-harm
Methods Double-blind, RCT
Participants Inclusion criteria: i) aged 18 years and older; ii) have a history of SH (lifetime); iii) sufficient language
ability
Exclusion criteria: i) not currently residing in an inpatient psychiatric facility
Interventions Intervention: electronic volitional help sheet. Participants read a brief statement designed to en-
courage them to avoid self-harming by forming implementation intentions by linking critical situa-
tions with appropriate alternative responses for each critical situation.
Comparator: analogue volitional help sheet
Outcomes Primary outcome(s): i) NSSI, as ascertained from self-report; ii) suicidal ideation, as ascertained
from self-report; iii) suicide attempts, as ascertained from self-report
Secondary outcome(s): i) exposure to suicide and mental imagery about death, as measured by a
seven-point scale adapted from Dhingra 2015; ii) capability, opportunity, and motivation, as mea-
sured by the Capability, Opportunity, Motivation Questionnaire; iii) habit, as measured by a self-re-

Informed decisions.
ported scale; iv) self-regulation, as measured by items adapted from Sniehotta 2005; v) frequency
with which critical situations were encountered and appropriate responses were used
Starting date 1 June, 2020
Dr. Chris Keyworth, University of Manchester, Manchester, UK (chris.keyworth@manchester.ac.uk)
Notes We are grateful to Dr. Chris Keyworth for confirming the above details were correct, 9 October,
2020.
O'Connor 2019
Study name SAFETEL randomised controlled feasibility trial of a safety planning intervention with follow-up
telephone contact to reduce suicidal behaviour: study protocol
Assignment: 2:1 allocation, individual-level
Participants Included: i) aged 18 years and older; ii) admitted to hospital following a suicide attempt; iii) as-
sessed by the Liaison Psychiatry team; iv) sufficient language ability
Excluded: i) no suicidal intent; ii) medically unfit for interview; iii) unable to provide informed con-
sent; iv) insufficient language ability; v) participating in another psychological intervention study
within the trial hospital; vi) no access to a telephone
Interventions Intervention: SAFETEL consisting of collaborative safety planning and five structured telephone
calls (around 15 minutes' duration each) over a period of four weeks. Therapeutic content involves:
i) safety planning; ii) suicide risk assessment; iii) mood monitoring; iv) reviewing and revising the
safety plan (as needed); v) treatment engagement enhancement; vi) motivational enhancement;
vii) problem-solving.
Comparator: TAU consisting of referral to any one of the following services as needed (e.g. prima-
ry care, community psychiatric service, third sector services, specialist mental health services, in-
tensive home treatment, outpatient services, transfer to inpatient care, social work, or no further
treatment)
Outcomes Primary outcome(s): i) repetition of SH, as measured by the C-SSRS and medical records; ii) feelings
of entrapment, as measured by the Entrapment Scale; iii) interpersonal functioning, as measured
by the Interpersonal Needs Questionnaire; iv) social functioning, as measured by the ENRICHD So-
cial Support Instrument; v) coping skills, as measured by the Suicide-Related Coping Scale
Prof. Rory O'Connor, University of Glasgow, Glasgow, UK (Rory.OConnor@glasgow.ac.uk)
Notes

Informed decisions.
SLCTR/2017/008
Study name A pilot randomised controlled trial to evaluate the acceptability and feasibility of a counselling in-
tervention, delivered by nurses, for those who have attempted self-poisoning in Sri Lanka
Assignment: parallel-group, blocked, individual-level
Participants Inclusion criteria: i) aged 16 years and older; ii) admitted to hospital for medical management fol-
lowing an episode of self-poisoning
Exclusion criteria: i) diagnosed with schizophrenia, any psychosis, bipolar disorder, dementia, intel-
lectual disability, or cognitive impairment; ii) physically too unwell to comply with the study proce-
dures
Interventions Intervention: brief Culturally-adapted Manually Assisted Problem-solving training (C-MAP) consist-
ing of one session (20-30 minutes' duration) of an adapted form of C-MAP
Comparator: TAU
Outcomes Primary outcome(s): i) coping skills, as measured by the Brief-COPE inventory; ii) alcohol use, as
measured by the Alcohol Use Disorders Identification Test (AUDIT); iii) depression, as measured by
the Patient Health Questionnaire 9 (PHQ-9) and the Peradeniya Depression Scale; iv) anxiety, as
measured by the Generalised Anxiety Disorder 7-item scale (GAD-7); v) suicidal intent, as measured
by the Pierce Suicide Intent Scale (PSIS)
Secondary outcome(s): acceptability, feasibility, and utility, as ascertained from qualitative inter-
views with participants
Starting date 27 March, 2017
Dr. Thillini Rajapakse, University of Peradeniya, Sri Lanka (gemba471@gmail.com)
Notes We are grateful to Dr. Thillini Rajapakse for confirming the above details were correct, 29 October,
2020.
Stevens 2019
Study name SMS SOS: using SMS text messages to prevent SH
Methods Open-label Zelen RCT
Assignment: parallel-group, individual-level, blocked randomisation stratified by multiple SH status
Participants Inclusion criteria: i) aged 16 years of age or older; ii) assessed in participating EDs following an
episode of SH; iii) sufficient language ability; iv) owns a mobile (cell) telephone
Exclusion criteria: i) no fixed address; ii) do not own a mobile (cell) telephone; iii) unable or unwill-
ing to provide informed consent
Interventions Intervention: series of nine SMS text messages delivered via mobile (cell) telephone at 1, 2, 3, 4, 5, 6,
8, 10, and 12 months' post-discharge. Messages are designed to express concern for participants'
well-being and to encourage them to make contact with local crisis services, if needed. Participants
will also receive TAU.

Informed decisions.
Stevens 2019 (Continued)

Comparator: TAU consisting of in- or outpatient mental health treatment, referral to other services
(e.g. AOD services), and/or GP management (as appropriate)
Outcomes Primary outcome(s): i) frequency of SH as ascertained from hospital records; ii) time to SH repeti-
tion as ascertained from hospital records
Secondary outcome(s): i) repetition of SH as ascertained from hospital records; ii) suicide as ascer-
tained from mortality registers; iii) all-cause mortality as ascertained from mortality registers
Dr. Garry Stevens, Western Sydney University, Sydney, New South Wales, Australia (g.steven-
s@westernsydney.edu.au)
Notes
ACSS-FAD: Acquired Capability for Suicide Scale-Fearlessness about Death

AEP:
AHSQ: Actual Help Seeking Questionnaire
AOD: alcohol and other drug
app: application
APSOM:
ASIQ: Adult Suicidal Ideation Questionnaire
ASSIP: Attempted Suicide Short Intervention Program
AUDIT: Alcohol Use Disorders Identification Test
BAI: Beck Anxiety Inventory
BAP:
BDI: Beck Depression Inventory
BHQ: Beck Hopelessness Scale
BHS(-4):
BIS: Barratt Impulsiveness Scale
BMF: Behavior Monitoring Form
BPD:
Brief-COPE:
BSI: Brief Symptom Inventory
BSSI:
CATCH:
CBT: cognitive behavioural therapy
CES-D: Center for Epidemiologic Studies Depression Scale
CISS: Coping Inventory for Stressful Situations
COPESS:
CORE-10: Clinical Outcomes in Routine Evaluation-10
C-MAP: Culturally-adapted Manually Assisted Problem-solving training
C-SSRS: Columbia-Suicide Severity Rating Scale
DBT: Dialectical Behaviour Therapy
DERS: Difficulties in Emotion Regulation Scale
DSH: deliberate self-harm
DSHI: Deliberate Self-Harm Interview
DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision
DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
ECT: electroconvulsive therapy
ED: emergency department
ENRICHD:
EQ-5D: European Quality of Life-5 Dimension
EMA: ecological momentary assessment
ERQ: Emotion Regulation Questionnaire
ESS: Experience of Shame Scale
EuroQoL-5D: European Quality of Life-5 Dimension
Informed decisions.
FASTER:
FFMQ: Five Facet Mindfulness Questionnaire
fMRI: functional magnetic resonance imaging
GAD-7:
GHSQ: General Help-Seeking Questionnaire
GP: general practitioner
HADS:
HARS: Hamilton Anxiety Rating Scale
HDRS: Hamilton Depression Rating Scale
HKSAR: Hong Kong Special Administrative Region
HRQ: Helping Relationship Questionnaire
ICD-10: International Classification of Diseases, 10th Revision
INQ-15: Interpersonal Needs Questionnaire-15
IIPSS: Independent-Interdependent Problem Solving Scale
IQ: intelligence quotient
ISAS:
ISI: Insomnia Severity Index
L-SASI:
MEAQ: Multi-dimensional Experiential Avoidance Questionnaire
MINI(-7):
MMSE: Mini Mental Status Examination
MRI: magnetic resonance imaging
MSP:
NEO:
NHS: National Health Service
NSSI: non-suicidal self-injury
N'VIU:
OASIS: Overall Anxiety Severity and Impairment Scale
ODSIS: Overall Depression Severity and Impairment Scale
OHIP:
PEPS:
PHQ-9: Patient Health Questionnaire 9
PSIS: Pierce Suicide Intent Scale
PTSD:
RCT: randomised controlled trial
READ: Resilience Scale for Adolescents
RRRS:
RSA: Resilience Scale for Adults
SAFETEL:
SASII:
SCID-BPD: Structured Clinical Interview for Borderline Personality Disorder
SCS: Self-Compassion Scale
SDQ:
SF-36:
SH: self-harm
SIAM:
SI-IAT: Self-Injury Implicit Association Test
SITBI: Self-Injurious Thoughts and Behaviors Interview
SMQ: Southampton Mindfulness Questionnaire
SMS: short messaging service
SOS:
SPP: Suicide Prevention Pathway
SSB: Social Support Behaviours Scale
SSS: Subjective Symptoms Scale
SURVIVE:
TAU: treatment-as-usual
vs:
WHOQOL-BREF:

Informed decisions.
RISK OF BIAS
Legend: Low risk of bias High risk of bias Some concerns
Risk of bias for analysis 1.1 Repetition of SH at post-intervention
Bias
Study Randomisation Deviations Missing Measurement Selection of Overall

process from intended outcome data of the outcome the reported
interventions results
Mousavi 2017
Stewart 2009
Wei 2013
Weinberg 2006
Risk of bias for analysis 2.1 Repetition of SH by post-intervention
Bias

Subgroup 2.1.1 Comparator: TAU
Linehan 1991
McMain 2009
Priebe 2012
Subgroup 2.1.2 Comparator: Alternative psychotherapy
Linehan 2006
Turner 2000
Walton 2020

Informed decisions.
Bias

Gratz 2006
Gratz 2014
Bias

Subgroup 4.1.1 TAU (whole sample)
Clarke 2002
Hvid 2011
Subgroup 4.1.2 Enhanced usual care (whole sample)
Kawanishi 2014
Morthorst 2012
Bias

Evans 1999a
Morgan 1993

Informed decisions.
Bias

Subgroup 6.1.1 Postcards (whole sample)
Beautrais 2010
Carter 2005
Hassan-
ian-Moghaddam
2011
Kapur 2013
Subgroup 6.1.2 Postcards (males)
Carter 2005
Subgroup 6.1.3 Postcards (females)
Carter 2005
Bias

Marasinghe 2012
Wei 2013

Informed decisions.
Bias

Amadéo 2015
Fleischmann 2008
Bias

Subgroup 9.1.1 Whole sample
Gysin-Maillart
2016
Hatcher 2015
Hatcher 2016
Subgroup 9.1.2 First SH episode
Hatcher 2015
Hatcher 2016
Subgroup 9.1.3 Repeat SH episode
Hatcher 2015
Hatcher 2016
DATA AND ANALYSES

Informed decisions.
Comparison 1. CBT-based psychotherapy
Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants
1.1 Repetition of SH at post-inter- 4 238 Odds Ratio (M-H, Random, 95% 0.35 [0.12, 1.02]
vention CI)
1.2 Repetition of SH at six months 12 1260 Odds Ratio (M-H, Random, 95% 0.52 [0.38, 0.70]
CI)
1.3 Repetition of SH at 12 months 9 2458 Odds Ratio (M-H, Random, 95% 0.81 [0.66, 0.99]
CI)
1.4 Repetition of SH at 24 months 2 105 Odds Ratio (M-H, Random, 95% 0.31 [0.14, 0.69]
CI)
1.5 Frequency of SH at post-inter- 4 149 Mean Difference (IV, Random, -0.53 [-1.67, 0.61]
vention 95% CI)
1.6 Frequency of SH at six months 4 118 Mean Difference (IV, Random, -0.71 [-1.32, -0.11]
95% CI)
1.7 Time to SH repetition 3 Hazard Ratio (IV, Random, 95% 0.81 [0.61, 1.08]
CI)
1.8 Depression scores at post-in- 5 953 Std. Mean Difference (IV, Ran- -0.28 [-0.54, -0.02]
tervention dom, 95% CI)
1.9 Depression scores at six 8 934 Std. Mean Difference (IV, Ran- -0.24 [-0.50, 0.01]
months dom, 95% CI)
1.10 Depression scores at 12 7 1130 Std. Mean Difference (IV, Ran- -0.36 [-0.64, -0.07]
months dom, 95% CI)
1.11 Depression scores at 24 2 225 Std. Mean Difference (IV, Ran- -0.22 [-0.48, 0.05]
months dom, 95% CI)
1.12 Hopelessness scores at post- 5 803 Mean Difference (IV, Random, -2.99 [-3.91, -2.07]
intervention 95% CI)
1.13 Hopelessness scores at six 2 315 Mean Difference (IV, Random, -3.14 [-4.78, -1.49]
months 95% CI)
1.14 Hopelessness scores at 12 3 539 Mean Difference (IV, Random, -1.89 [-2.97, -0.81]
months 95% CI)
1.15 Suicidal ideation scores at 5 718 Std. Mean Difference (IV, Ran- -0.48 [-0.68, -0.28]
post-intervention dom, 95% CI)
1.16 Suicidal ideation scores at 4 353 Std. Mean Difference (IV, Ran- -0.38 [-0.60, -0.17]
six months dom, 95% CI)
1.17 Proportion reporting suici- 2 Odds Ratio (M-H, Random, 95% Subtotals only
dal ideation CI)
1.17.1 Post-intervention 2 219 Odds Ratio (M-H, Random, 95% 0.44 [0.08, 2.26]
CI)

Informed decisions.
pants
1.17.2 Six months 1 159 Odds Ratio (M-H, Random, 95% 1.27 [0.66, 2.46]
CI)
1.17.3 12 months 1 159 Odds Ratio (M-H, Random, 95% 1.20 [0.62, 2.31]
CI)
1.18 Suicide deaths by final fol- 16 2130 Odds Ratio (M-H, Random, 95% 0.79 [0.34, 1.80]
low-up CI)
1.19 Repetition of SH at 12 2 Odds Ratio (M-H, Random, 95% Subtotals only

months (by repeater status) CI)
1.19.1 History of prior SH 2 508 Odds Ratio (M-H, Random, 95% 0.56 [0.36, 0.88]
CI)
1.19.2 No history of prior SH 2 733 Odds Ratio (M-H, Random, 95% 1.10 [0.48, 2.52]
CI)
Analysis 1.1. Comparison 1: CBT-based psychotherapy, Outcome 1: Repetition of SH at post-intervention

CBT-based psychotherapy Comparator Odds Ratio Odds Ratio Risk of Bias
Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI A B C D E F
Mousavi 2017 2 30 6 30 40.0% 0.29 [0.05 , 1.55] ? ? + ? ? ?

Stewart 2009 3 23 2 9 29.0% 0.53 [0.07 , 3.82] ? + + + ? ?
Wei 2013 0 55 1 61 11.0% 0.36 [0.01 , 9.11] ? + - ? ? -
Weinberg 2006 12 15 14 15 20.0% 0.29 [0.03 , 3.12] + + + ? ? ?
Total (95% CI) 123 115 100.0% 0.35 [0.12 , 1.02]

Total events: 17 23
Heterogeneity: Tau² = 0.00; Chi² = 0.25, df = 3 (P = 0.97); I² = 0% 0.1 0.2 0.5 1 2 5 10
Test for overall effect: Z = 1.92 (P = 0.05) Favours CBT Favours comparator
Test for subgroup differences: Not applicable
Risk of bias legend

(A) Bias arising from the randomization process
(B) Bias due to deviations from intended interventions: Repetition of SH at post-intervention
(C) Bias due to missing outcome data: Repetition of SH at post-intervention
(D) Bias in measurement of the outcome: Repetition of SH at post-intervention
(E) Bias in selection of the reported result: Repetition of SH at post-intervention
(F) Overall bias: Repetition of SH at post-intervention

Informed decisions.
Analysis 1.2. Comparison 1: CBT-based psychotherapy, Outcome 2: Repetition of SH at six months
CBT-based psychotherapy Comparator Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Brown 2005 9 50 18 52 10.6% 0.41 [0.17 , 1.04]

Davidson 2014 4 10 4 4 0.9% 0.08 [0.00 , 1.81]
Evans 1999b 10 18 10 14 4.1% 0.50 [0.11 , 2.21]
Guthrie 2001 5 58 17 61 7.8% 0.24 [0.08 , 0.71]
Husain 2014 1 102 1 111 1.2% 1.09 [0.07 , 17.64]
Lin 2020 11 72 24 75 13.7% 0.38 [0.17 , 0.86]
Owens 2020 7 30 12 32 7.4% 0.51 [0.17 , 1.54]
Salkovskis 1990 0 12 3 8 0.9% 0.06 [0.00 , 1.44]
Tapolaa 2010 2 9 4 7 2.0% 0.21 [0.02 , 1.88]
Tyrer 2003 64 213 77 217 47.9% 0.78 [0.52 , 1.17]
Wei 2013 1 35 4 40 1.8% 0.26 [0.03 , 2.49]
Weinberg 2006 12 15 14 15 1.6% 0.29 [0.03 , 3.12]
Total (95% CI) 624 636 100.0% 0.52 [0.38 , 0.70]

Total events: 126 188
Test for overall effect: Z = 4.22 (P < 0.0001) Favours CBT Favours comparator
Analysis 1.3. Comparison 1: CBT-based psychotherapy, Outcome 3: Repetition of SH at 12 months

Brown 2005 12 49 23 49 5.6% 0.37 [0.16 , 0.87]

Dubois 1999 8 43 10 41 3.8% 0.71 [0.25 , 2.02]
Gibbons 1978 27 200 29 200 13.0% 0.92 [0.52 , 1.62]
Hatcher 2011 70 522 81 572 35.1% 0.94 [0.67 , 1.32]
Hawton 1987 3 41 6 39 1.9% 0.43 [0.10 , 1.87]
Lin 2020 15 72 18 75 6.9% 0.83 [0.38 , 1.81]
Slee 2008 26 40 21 33 4.5% 1.06 [0.41 , 2.78]
Tyrer 2003 84 213 99 217 28.3% 0.78 [0.53 , 1.14]
Wei 2013 1 25 5 27 0.8% 0.18 [0.02 , 1.69]
Total (95% CI) 1205 1253 100.0% 0.81 [0.66 , 0.99]

Analysis 1.4. Comparison 1: CBT-based psychotherapy, Outcome 4: Repetition of SH at 24 months

Brown 2005 13 45 23 40 81.8% 0.30 [0.12 , 0.74]

Salkovskis 1990 3 12 4 8 18.2% 0.33 [0.05 , 2.24]
Total (95% CI) 57 48 100.0% 0.31 [0.14 , 0.69]

Total events: 16 27

Informed decisions.
Analysis 1.5. Comparison 1: CBT-based psychotherapy, Outcome 5: Frequency of SH at post-intervention

CBT-based psychotherapy Comparator Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Slee 2008 5.3 9.44 40 4.04 7.16 34 7.6% 1.26 [-2.53 , 5.05]
Stewart 2009 0.33 0.63 23 0.22 0.5 9 45.1% 0.11 [-0.31 , 0.53]
Tapolaa 2010 0.17 0.41 6 0.86 1.46 7 32.6% -0.69 [-1.82 , 0.44]
Weinberg 2006 0.6 0.91 15 3.63 4.8 15 14.7% -3.03 [-5.50 , -0.56]
Total (95% CI) 84 65 100.0% -0.53 [-1.67 , 0.61]

Heterogeneity: Tau² = 0.71; Chi² = 7.84, df = 3 (P = 0.05); I² = 62%
Test for overall effect: Z = 0.90 (P = 0.37) -10 -5 0 5 10
Test for subgroup differences: Not applicable Favours CBT Favours comparator
Analysis 1.6. Comparison 1: CBT-based psychotherapy, Outcome 6: Frequency of SH at six months

Davidson 2014 2.1 3.51 10 10 11.53 3 0.2% -7.90 [-21.13 , 5.33]

Owens 2020 0.6 1.28 30 1.4 2.43 32 39.9% -0.80 [-1.76 , 0.16]
Tapolaa 2010 0.43 0.54 6 1 0.89 7 59.0% -0.57 [-1.36 , 0.22]
Weinberg 2006 1.98 3.57 15 6.69 12.23 15 0.9% -4.71 [-11.16 , 1.74]
Total (95% CI) 61 57 100.0% -0.71 [-1.32 , -0.11]

Analysis 1.7. Comparison 1: CBT-based psychotherapy, Outcome 7: Time to SH repetition
Hazard Ratio Hazard Ratio

Study or Subgroup log[Hazard Ratio] SE Weight IV, Random, 95% CI IV, Random, 95% CI
Brown 2005 -0.67 0.34 15.6% 0.51 [0.26 , 1.00]

Hatcher 2011 -0.02 0.17 42.2% 0.98 [0.70 , 1.37]
Tyrer 2003 -0.22 0.17 42.2% 0.80 [0.58 , 1.12]
Total (95% CI) 100.0% 0.81 [0.61 , 1.08]

Test for overall effect: Z = 1.40 (P = 0.16) 0.01 0.1 1 10 100
Analysis 1.8. Comparison 1: CBT-based psychotherapy, Outcome 8: Depression scores at post-intervention

CBT-based psychotherapy Comparator Std. Mean Difference Std. Mean Difference
Brown 2005 19.96 14.82 60 21.19 14.92 60 18.8% -0.08 [-0.44 , 0.28]
Hatcher 2011 5.2 4.3 196 7.5 5.1 230 25.4% -0.48 [-0.68 , -0.29]
Husain 2014 13 16.2 105 17.1 16.4 112 22.4% -0.25 [-0.52 , 0.02]
Slee 2008 16.58 13.7 40 28.56 18.62 34 14.8% -0.73 [-1.21 , -0.26]
Wei 2013 8.43 10.45 55 7.14 8.33 61 18.6% 0.14 [-0.23 , 0.50]
Total (95% CI) 456 497 100.0% -0.28 [-0.54 , -0.02]

Test for overall effect: Z = 2.12 (P = 0.03) -1 -0.5 0 0.5 1

Informed decisions.
Analysis 1.9. Comparison 1: CBT-based psychotherapy, Outcome 9: Depression scores at six months
Brown 2005 13.82 12.34 50 19.33 15.61 52 15.4% -0.39 [-0.78 , 0.00]
Davidson 2014 9.27 5.73 11 16.75 1.5 4 3.3% -1.39 [-2.67 , -0.10]
Evans 1999b 5.7 5.5 18 10.1 4.1 14 8.0% -0.87 [-1.60 , -0.13]
Guthrie 2001 18.5 13.5 47 24 12.5 48 15.0% -0.42 [-0.83 , -0.01]
Husain 2014 14.8 17.3 102 19.4 16.9 111 19.1% -0.27 [-0.54 , 0.00]
Tapolaa 2010 25 13.57 6 24.71 11.87 7 4.4% 0.02 [-1.07 , 1.11]
Tyrer 2003 7.9 5.3 195 7.5 5.3 194 21.2% 0.08 [-0.12 , 0.27]
Wei 2013 7.82 10.38 35 5.85 8.16 40 13.6% 0.21 [-0.24 , 0.67]
Total (95% CI) 464 470 100.0% -0.24 [-0.50 , 0.01]

Analysis 1.10. Comparison 1: CBT-based psychotherapy, Outcome 10: Depression scores at 12 months
Brown 2005 13.59 13.4 49 18.73 13.87 49 15.4% -0.37 [-0.77 , 0.03]
Hatcher 2011 5.3 4.7 190 6.2 4.8 232 19.9% -0.19 [-0.38 , 0.00]
Hawton 1987 6.5 8.26 30 9.6 10.96 35 13.4% -0.31 [-0.80 , 0.18]
Salkovskis 1990 15 6.16 12 23 6.16 8 6.1% -1.24 [-2.24 , -0.25]
Slee 2008 11.58 12.12 40 29.61 17.51 33 13.1% -1.21 [-1.71 , -0.70]
Tyrer 2003 7 5.3 198 7.1 5.2 202 19.8% -0.02 [-0.22 , 0.18]
Wei 2013 7.26 10.58 25 5.84 8.23 27 12.3% 0.15 [-0.40 , 0.69]
Total (95% CI) 544 586 100.0% -0.36 [-0.64 , -0.07]

Analysis 1.11. Comparison 1: CBT-based psychotherapy, Outcome 11: Depression scores at 24 months
Brown 2005 14.51 12.9 45 18.18 13.75 40 37.6% -0.27 [-0.70 , 0.15]
Gibbons 1978 10.57 11.39 69 12.62 10.95 71 62.4% -0.18 [-0.51 , 0.15]
Total (95% CI) 114 111 100.0% -0.22 [-0.48 , 0.05]


Informed decisions.
Analysis 1.12. Comparison 1: CBT-based psychotherapy, Outcome 12: Hopelessness scores at post-intervention
Brown 2005 7.45 4.99 60 9.06 6.98 60 17.8% -1.61 [-3.78 , 0.56]
Hatcher 2011 5.7 5.5 193 8.9 6.6 226 62.6% -3.20 [-4.36 , -2.04]
Husain 2014 7.9 8.7 105 11.3 8.9 112 15.3% -3.40 [-5.74 , -1.06]
Patsiokas 1985 3.3 2.34 10 9 7.8 5 1.7% -5.70 [-12.69 , 1.29]
Stewart 2009 4.35 4.22 23 7.56 8.53 9 2.5% -3.21 [-9.04 , 2.62]
Total (95% CI) 391 412 100.0% -2.99 [-3.91 , -2.07]

Test for overall effect: Z = 6.39 (P < 0.00001) -10 -5 0 5 10
Analysis 1.13. Comparison 1: CBT-based psychotherapy, Outcome 13: Hopelessness scores at six months
Brown 2005 5.57 4.47 50 8.21 6.96 52 53.1% -2.64 [-4.90 , -0.38]
Husain 2014 7.5 8.8 102 11.2 9.1 111 46.9% -3.70 [-6.10 , -1.30]
Total (95% CI) 152 163 100.0% -3.14 [-4.78 , -1.49]

Analysis 1.14. Comparison 1: CBT-based psychotherapy, Outcome 14: Hopelessness scores at 12 months
Brown 2005 6.57 5.76 49 8.22 6.77 52 17.6% -1.65 [-4.10 , 0.80]
Hatcher 2011 5.8 5.8 189 7.2 6.4 229 58.4% -1.40 [-2.57 , -0.23]
Salkovskis 1990 6.75 2.3 12 10 2.3 8 24.0% -3.25 [-5.31 , -1.19]
Total (95% CI) 250 289 100.0% -1.89 [-2.97 , -0.81]

Analysis 1.15. Comparison 1: CBT-based psychotherapy, Outcome 15: Suicidal ideation scores at post-intervention
Hatcher 2011 3.7 6.8 194 7.1 8.6 230 50.3% -0.43 [-0.63 , -0.24]
Husain 2014 7.1 9.8 105 10.5 9.6 112 34.8% -0.35 [-0.62 , -0.08]
Patsiokas 1985 5.1 5.29 10 8.6 9.2 5 3.2% -0.49 [-1.58 , 0.60]
Stewart 2009 1.91 4.07 23 10.11 12.67 9 5.5% -1.08 [-1.90 , -0.26]
Weinberg 2006 24.47 16.92 15 42.69 17.67 15 6.2% -1.02 [-1.79 , -0.26]
Total (95% CI) 347 371 100.0% -0.48 [-0.68 , -0.28]


Informed decisions.
Analysis 1.16. Comparison 1: CBT-based psychotherapy, Outcome 16: Suicidal ideation scores at six months
Davidson 2014 12.36 12.48 11 26.5 1.92 4 2.9% -1.21 [-2.46 , 0.04]
Guthrie 2001 8.3 8.6 47 12.1 10.4 48 27.2% -0.39 [-0.80 , 0.01]
Husain 2014 7.8 10.7 102 11.3 10.4 111 61.4% -0.33 [-0.60 , -0.06]
Weinberg 2006 37.96 18.68 15 45.69 14.38 15 8.5% -0.45 [-1.18 , 0.27]
Total (95% CI) 175 178 100.0% -0.38 [-0.60 , -0.17]

Analysis 1.17. Comparison 1: CBT-based psychotherapy, Outcome 17: Proportion reporting suicidal ideation

1.17.1 Post-intervention
Mousavi 2017 7 30 19 30 46.0% 0.18 [0.06 , 0.54]
Wei 2013 33 82 32 77 54.0% 0.95 [0.50 , 1.78]
Subtotal (95% CI) 112 107 100.0% 0.44 [0.08 , 2.26]
Total events: 40 51
Test for overall effect: Z = 0.99 (P = 0.32)
1.17.2 Six months

Wei 2013 30 82 24 77 100.0% 1.27 [0.66 , 2.46]
Subtotal (95% CI) 82 77 100.0% 1.27 [0.66 , 2.46]
Total events: 30 24
Heterogeneity: Not applicable
1.17.3 12 months
Wei 2013 30 82 25 77 100.0% 1.20 [0.62 , 2.31]
Subtotal (95% CI) 82 77 100.0% 1.20 [0.62 , 2.31]
Total events: 30 25
0.01 0.1 1 10 100

Favours CBT Favours comparator

Informed decisions.
Analysis 1.18. Comparison 1: CBT-based psychotherapy, Outcome 18: Suicide deaths by final follow-up

Brown 2005 0 60 1 60 6.6% 0.33 [0.01 , 8.21]

Davidson 2014 1 10 0 4 6.0% 1.42 [0.05 , 42.22]
Dubois 1999 0 51 0 51 Not estimable
Guthrie 2001 0 58 0 61 Not estimable
Hatcher 2011 3 253 4 299 30.2% 0.89 [0.20 , 3.99]
Hawton 1987 1 41 0 39 6.6% 2.93 [0.12 , 74.00]
Husain 2014 2 102 2 111 17.5% 1.09 [0.15 , 7.88]
Lin 2020 2 72 1 75 11.7% 2.11 [0.19 , 23.84]
Owens 2020 0 30 0 32 Not estimable
Salkovskis 1990 0 12 0 8 Not estimable
Slee 2008 0 48 1 42 6.6% 0.29 [0.01 , 7.19]
Stewart 2009 0 23 0 9 Not estimable
Tapolaa 2010 0 9 0 7 Not estimable
Tyrer 2003 1 239 5 241 14.8% 0.20 [0.02 , 1.71]
Wei 2013 0 26 0 27 Not estimable
Weinberg 2006 0 15 0 15 Not estimable
Total (95% CI) 1049 1081 100.0% 0.79 [0.34 , 1.80]

Total events: 10 14
Heterogeneity: Tau² = 0.00; Chi² = 3.78, df = 7 (P = 0.80); I² = 0% 0.01 0.1 1 10 100
Analysis 1.19. Comparison 1: CBT-based psychotherapy,

Outcome 19: Repetition of SH at 12 months (by repeater status)

1.19.1 History of prior SH

Hatcher 2011 28 208 47 212 75.6% 0.55 [0.33 , 0.91]
Lin 2020 11 39 19 49 24.4% 0.62 [0.25 , 1.53]
Subtotal (95% CI) 247 261 100.0% 0.56 [0.36 , 0.88]
Total events: 39 66
1.19.2 No history of prior SH

Hatcher 2011 42 314 34 360 67.1% 1.48 [0.92 , 2.39]
Lin 2020 8 33 9 26 32.9% 0.60 [0.19 , 1.88]
Subtotal (95% CI) 347 386 100.0% 1.10 [0.48 , 2.52]
Total events: 50 43
Test for subgroup differences: Chi² = 1.97, df = 1 (P = 0.16), I² = 49.3% 0.1 0.2 0.5 1 2 5 10
Favours CBT Favours comparator
Comparison 2. DBT
pants
2.1 Repetition of SH by post-in- 6 502 Odds Ratio (M-H, Random, 95% 0.71 [0.32, 1.55]
tervention CI)

Informed decisions.
pants
2.1.1 Comparator: TAU 3 267 Odds Ratio (M-H, Random, 95% 0.59 [0.16, 2.15]
CI)
2.1.2 Comparator: Alternative 3 235 Odds Ratio (M-H, Random, 95% 0.67 [0.16, 2.78]
psychotherapy CI)
2.2 Repetition of SH by 12 3 269 Odds Ratio (M-H, Random, 95% 0.65 [0.24, 1.72]
months CI)
CI)
psychotherapy CI)
2.3 Frequency of SH by post-in- 7 659 Mean Difference (IV, Random, -5.00 [-8.92, -1.08]
tervention 95% CI)
2.3.1 Comparator: TAU 4 376 Mean Difference (IV, Random, -10.09 [-21.57, 1.40]
95% CI)
2.3.2 Comparator: Alternative 3 283 Mean Difference (IV, Random, -5.00 [-7.91, -2.09]
psychotherapy 95% CI)
2.4 Treatment adherence: Pro- 4 467 Odds Ratio (M-H, Random, 95% 1.40 [0.73, 2.67]
portion completing treatment CI)
CI)
psychotherapy CI)
2.5 Depression scores by post-in- 6 557 Std. Mean Difference (IV, Ran- -0.37 [-0.58, -0.17]
tervention dom, 95% CI)
2.5.1 Comparator: TAU 3 282 Std. Mean Difference (IV, Ran- -0.27 [-0.50, -0.03]
dom, 95% CI)
2.5.2 Comparator: Alternative 3 275 Std. Mean Difference (IV, Ran- -0.50 [-0.85, -0.14]
psychotherapy dom, 95% CI)
2.6 Suicidal ideation scores by 3 194 Std. Mean Difference (IV, Ran- -0.31 [-0.64, 0.02]
post-intervention dom, 95% CI)
2.6.1 Comparator: TAU 1 81 Std. Mean Difference (IV, Ran- -0.34 [-0.78, 0.10]
dom, 95% CI)
2.6.2 Comparator: Alternative 2 113 Std. Mean Difference (IV, Ran- -0.40 [-1.11, 0.31]
psychotherapy dom, 95% CI)
2.7 Suicide deaths by post-inter- 5 563 Odds Ratio (M-H, Random, 95% 3.00 [0.12, 76.49]
vention CI)

Informed decisions.
pants
CI)
2.7.2 Comparator: Alternative 1 162 Odds Ratio (M-H, Random, 95% Not estimable
psychotherapy CI)
2.8 Suicide deaths by 12 months 2 254 Odds Ratio (M-H, Random, 95% Not estimable
CI)
2.8.1 Comparator: TAU 2 254 Odds Ratio (M-H, Random, 95% Not estimable
CI)
psychotherapy CI)
2.9 Suicide deaths by 24 months 2 254 Odds Ratio (M-H, Random, 95% Not estimable
CI)
2.9.1 Comparator: TAU 2 254 Odds Ratio (M-H, Random, 95% Not estimable
CI)
psychotherapy CI)

Informed decisions.
Analysis 2.1. Comparison 2: DBT, Outcome 1: Repetition of SH by post-intervention
DBT Comparator Odds Ratio Odds Ratio Risk of Bias

2.1.1 Comparator: TAU

Linehan 1991 14 22 21 22 9.1% 0.08 [0.01 , 0.74] + ? - - ? -
McMain 2009 33 70 36 78 26.2% 1.04 [0.54 , 1.99] + + + + ? ?
Priebe 2012 34 37 35 38 13.0% 0.97 [0.18 , 5.15] ? + + ? ? ?
Subtotal (95% CI) 129 138 48.4% 0.59 [0.16 , 2.15]
Total events: 81 92
2.1.2 Comparator: Alternative psychotherapy

Linehan 2006 46 52 37 45 19.0% 1.66 [0.53 , 5.20] ? ? + + ? ?
Turner 2000 1 12 8 12 8.1% 0.05 [0.00 , 0.49] ? + + - ? -
Walton 2020 33 51 39 63 24.5% 1.13 [0.52 , 2.43] + + + ? ? ?
Subtotal (95% CI) 115 120 51.6% 0.67 [0.16 , 2.78]
Total events: 80 84
Total (95% CI) 244 258 100.0% 0.71 [0.32 , 1.55]

Test for overall effect: Z = 0.87 (P = 0.39) Favours DBT Favours comparator
Test for subgroup differences: Chi² = 0.02, df = 1 (P = 0.90), I² = 0%
Risk of bias legend

(B) Bias due to deviations from intended interventions: Repetition of SH by post-intervention
(C) Bias due to missing outcome data: Repetition of SH by post-intervention
(D) Bias in measurement of the outcome: Repetition of SH by post-intervention
(E) Bias in selection of the reported result: Repetition of SH by post-intervention
(F) Overall bias: Repetition of SH by post-intervention
Analysis 2.2. Comparison 2: DBT, Outcome 2: Repetition of SH by 12 months
DBT Comparator Odds Ratio Odds Ratio


Linehan 1991 15 22 21 22 15.6% 0.10 [0.01 , 0.92]
McMain 2009 17 59 24 69 50.2% 0.76 [0.36 , 1.61]
Subtotal (95% CI) 81 91 65.8% 0.36 [0.05 , 2.47]
Total events: 32 45

Linehan 2006 46 52 39 45 34.2% 1.18 [0.35 , 3.95]
Subtotal (95% CI) 52 45 34.2% 1.18 [0.35 , 3.95]
Total events: 46 39
Total (95% CI) 133 136 100.0% 0.65 [0.24 , 1.72]

Total events: 78 84
Test for subgroup differences: Chi² = 1.03, df = 1 (P = 0.31), I² = 3.1%

Informed decisions.
Analysis 2.3. Comparison 2: DBT, Outcome 3: Frequency of SH by post-intervention
DBT Comparator Mean Difference Mean Difference


Linehan 1991 6.82 12.35 22 33.54 69.97 22 1.7% -26.72 [-56.41 , 2.97]
McMain 2009 4.29 9.32 90 12.87 51.45 90 10.1% -8.58 [-19.38 , 2.22]
McMain 2017 1.14 3.26 42 2.59 6.9 42 38.3% -1.45 [-3.76 , 0.86]
Priebe 2012 27.2 42 31 65.1 93.8 37 1.3% -37.90 [-71.55 , -4.25]
Subtotal (95% CI) 185 191 51.4% -10.09 [-21.57 , 1.40]

Linehan 2006 8.79 10.81 52 23.64 77.34 45 2.8% -14.85 [-37.64 , 7.94]
Turner 2000 0.75 1.23 12 5.58 5.28 12 34.8% -4.83 [-7.90 , -1.76]
Walton 2020 10.1 35.95 81 15 30.09 81 11.0% -4.90 [-15.11 , 5.31]
Subtotal (95% CI) 145 138 48.6% -5.00 [-7.91 , -2.09]
Total (95% CI) 330 329 100.0% -5.00 [-8.92 , -1.08]

Test for subgroup differences: Chi² = 0.71, df = 1 (P = 0.40), I² = 0% Favours DBT Favours comparator
Analysis 2.4. Comparison 2: DBT, Outcome 4: Treatment adherence: Proportion completing treatment


McMain 2009 55 90 56 90 32.8% 0.95 [0.52 , 1.74]
Subtotal (95% CI) 90 90 32.8% 0.95 [0.52 , 1.74]
Total events: 55 56

Linehan 2006 42 52 28 49 24.4% 3.15 [1.29 , 7.69]
Turner 2000 9 12 6 12 10.7% 3.00 [0.53 , 16.90]
Walton 2020 45 81 48 81 32.1% 0.86 [0.46 , 1.60]
Subtotal (95% CI) 145 142 67.2% 1.79 [0.65 , 4.89]
Total events: 96 82
Total (95% CI) 235 232 100.0% 1.40 [0.73 , 2.67]

Test for subgroup differences: Chi² = 1.10, df = 1 (P = 0.29), I² = 8.9%

Informed decisions.
Analysis 2.5. Comparison 2: DBT, Outcome 5: Depression scores by post-intervention
DBT Comparator Std. Mean Difference Std. Mean Difference


Linehan 1991 21 7.48 7 21.91 14.85 11 4.3% -0.07 [-1.02 , 0.88]
McMain 2009 22.18 16.14 90 24.83 14.83 90 29.2% -0.17 [-0.46 , 0.12]
McMain 2017 22.76 12.55 42 29.73 13.5 42 16.8% -0.53 [-0.97 , -0.09]
Subtotal (95% CI) 139 143 50.4% -0.27 [-0.50 , -0.03]

Linehan 2006 14 7.3 50 17 8.2 39 17.6% -0.39 [-0.81 , 0.04]
Turner 2000 14.92 8.26 12 24.08 5.55 12 4.9% -1.26 [-2.15 , -0.37]
Walton 2020 15.94 14.52 81 22.13 17.78 81 27.1% -0.38 [-0.69 , -0.07]
Subtotal (95% CI) 143 132 49.6% -0.50 [-0.85 , -0.14]
Total (95% CI) 282 275 100.0% -0.37 [-0.58 , -0.17]

Test for subgroup differences: Chi² = 1.11, df = 1 (P = 0.29), I² = 10.2% Favours DBT Favours comparator
Analysis 2.6. Comparison 2: DBT, Outcome 6: Suicidal ideation scores by post-intervention
DBT Comparator Std. Mean Difference Std. Mean Difference


Linehan 1991 24.01 19.8 46 31.92 26.8 35 41.3% -0.34 [-0.78 , 0.10]
Subtotal (95% CI) 46 35 41.3% -0.34 [-0.78 , 0.10]

Linehan 2006 29.8 24.5 50 32.8 26.3 39 44.8% -0.12 [-0.54 , 0.30]
Turner 2000 3.83 8.03 12 11.58 9.21 12 13.9% -0.87 [-1.71 , -0.02]
Subtotal (95% CI) 62 51 58.7% -0.40 [-1.11 , 0.31]
Total (95% CI) 108 86 100.0% -0.31 [-0.64 , 0.02]

Test for subgroup differences: Chi² = 0.02, df = 1 (P = 0.89), I² = 0% Favours DBT Favours comparator

Informed decisions.
Analysis 2.7. Comparison 2: DBT, Outcome 7: Suicide deaths by post-intervention


Linehan 1991 1 32 0 31 100.0% 3.00 [0.12 , 76.49]
McMain 2009 0 90 0 90 Not estimable
Priebe 2012 0 38 0 36 Not estimable
Subtotal (95% CI) 202 199 100.0% 3.00 [0.12 , 76.49]
Total events: 1 0

Walton 2020 0 81 0 81 Not estimable
Subtotal (95% CI) 81 81 Not estimable
Total events: 0 0
Test for overall effect: Not applicable
Total (95% CI) 283 280 100.0% 3.00 [0.12 , 76.49]

Total events: 1 0
Heterogeneity: Not applicable 0.01 0.1 1 10 100
Analysis 2.8. Comparison 2: DBT, Outcome 8: Suicide deaths by 12 months


Total events: 0 0

Total events: 0 0
Total (95% CI) 128 126 Not estimable

Total events: 0 0
Test for overall effect: Not applicable Favours DBT Favours comparator

Informed decisions.
Analysis 2.9. Comparison 2: DBT, Outcome 9: Suicide deaths by 24 months


Total events: 0 0

Total events: 0 0
Total (95% CI) 128 126 Not estimable

Total events: 0 0
Test for overall effect: Not applicable Favours DBT Favours comparator
Comparison 3. Group-based emotion-regulation psychotherapy
pants
3.1 Repetition of SH at post-interven- 2 83 Odds Ratio (M-H, Random, 0.34 [0.13, 0.88]
tion 95% CI)
3.2 Frequency of repetition of SH at 2 83 Mean Difference (IV, Ran- -12.76 [-34.92,

post-intervention dom, 95% CI) 9.40]
3.3 Depression scores at post-interven- 2 83 Mean Difference (IV, Ran- -9.59 [-13.43,
tion dom, 95% CI) -5.75]

Informed decisions.
Analysis 3.1. Comparison 3: Group-based emotion-regulation

psychotherapy, Outcome 1: Repetition of SH at post-intervention
Emotion-regulation Comparator Odds Ratio Odds Ratio Risk of Bias
Gratz 2006 6 12 7 10 29.5% 0.43 [0.07 , 2.50] ? ? + + ? ?

Gratz 2014 17 31 24 30 70.5% 0.30 [0.10 , 0.95] ? + + ? ? ?
Total (95% CI) 43 40 100.0% 0.34 [0.13 , 0.88]

Total events: 23 31
Test for overall effect: Z = 2.23 (P = 0.03) Favours ER Favours comparator
Risk of bias legend

Analysis 3.2. Comparison 3: Group-based emotion-regulation psychotherapy,

Outcome 2: Frequency of repetition of SH at post-intervention
Emotion-regulation Comparator Mean Difference Mean Difference

Gratz 2006 5 4.94 12 30.33 35.08 10 44.7% -25.33 [-47.25 , -3.41]

Gratz 2014 16.67 39.74 31 19.26 24.25 30 55.3% -2.59 [-19.05 , 13.87]
Total (95% CI) 43 40 100.0% -12.76 [-34.92 , 9.40]

Test for subgroup differences: Not applicable Favours ER Favours comparator
Analysis 3.3. Comparison 3: Group-based emotion-regulation

psychotherapy, Outcome 3: Depression scores at post-intervention
Emotion-regulation Comparator Mean Difference Mean Difference

Gratz 2006 9 6.52 12 23.2 15.32 10 14.2% -14.20 [-24.39 , -4.01]

Gratz 2014 19.98 8.26 31 28.81 8.26 30 85.8% -8.83 [-12.98 , -4.68]
Total (95% CI) 43 40 100.0% -9.59 [-13.43 , -5.75]

Test for subgroup differences: Not applicable Favours ER Favours comparator
Comparison 4. Case management
pants
4.1 Repetition of SH at post-in- 4 1608 Odds Ratio (M-H, Random, 95% 0.78 [0.47, 1.30]
tervention CI)

Informed decisions.
pants
4.1.1 TAU (whole sample) 2 600 Odds Ratio (M-H, Random, 95% 0.59 [0.25, 1.40]
CI)
4.1.2 Enhanced usual care 2 1008 Odds Ratio (M-H, Random, 95% 0.99 [0.42, 2.31]
(whole sample) CI)
4.2 Suicide deaths at post-inter- 4 1757 Odds Ratio (M-H, Random, 95% 0.95 [0.57, 1.57]
vention CI)
4.2.1 TAU 2 600 Odds Ratio (M-H, Random, 95% 1.50 [0.24, 9.35]
CI)
4.2.2 Enhanced usual care 2 1157 Odds Ratio (M-H, Random, 95% 0.91 [0.54, 1.55]
CI)
Analysis 4.1. Comparison 4: Case management, Outcome 1: Repetition of SH at post-intervention

Case management Comparator Odds Ratio Odds Ratio Risk of Bias
4.1.1 TAU (whole sample)

Clarke 2002 19 220 25 247 27.7% 0.84 [0.45 , 1.57] + + + + ? ?
Hvid 2011 6 69 14 64 16.2% 0.34 [0.12 , 0.95] + + + + ? ?
Subtotal (95% CI) 289 311 43.9% 0.59 [0.25 , 1.40]
Total events: 25 39
4.1.2 Enhanced usual care (whole sample)

Kawanishi 2014 28 380 41 385 32.6% 0.67 [0.40 , 1.10] + + + + ? ?
Morthorst 2012 20 123 13 120 23.5% 1.60 [0.76 , 3.38] + + + + ? ?
Subtotal (95% CI) 503 505 56.1% 0.99 [0.42 , 2.31]
Total events: 48 54
Total (95% CI) 792 816 100.0% 0.78 [0.47 , 1.30]

Total events: 73 93
Test for overall effect: Z = 0.95 (P = 0.34) Favours case management Favours comparator
Risk of bias legend


Informed decisions.
Analysis 4.2. Comparison 4: Case management, Outcome 2: Suicide deaths at post-intervention
Case management Comparator Odds Ratio Odds Ratio

4.2.1 TAU
Clarke 2002 1 220 1 247 3.4% 1.12 [0.07 , 18.07]
Hvid 2011 2 69 1 64 4.4% 1.88 [0.17 , 21.25]
Subtotal (95% CI) 289 311 7.8% 1.50 [0.24 , 9.35]
Total events: 3 2
4.2.2 Enhanced usual care

Kawanishi 2014 27 460 30 454 89.7% 0.88 [0.52 , 1.51]
Morthorst 2012 1 123 0 120 2.5% 2.95 [0.12 , 73.16]
Subtotal (95% CI) 583 574 92.2% 0.91 [0.54 , 1.55]
Total events: 28 30
Total (95% CI) 872 885 100.0% 0.95 [0.57 , 1.57]

Total events: 31 32
Test for overall effect: Z = 0.21 (P = 0.83) Favours case management Favours comparator
Comparison 5. Remote contact interventions: Emergency cards
pants
5.1 Repetition of SH at post-inter- 2 1039 Odds Ratio (M-H, Random, 0.82 [0.31, 2.14]
vention 95% CI)
5.2 Repetition of SH at 12 months 1 Odds Ratio (M-H, Random, Subtotals only

95% CI)
5.2.1 Emergency cards (whole sam- 1 827 Odds Ratio (M-H, Random, 1.19 [0.85, 1.67]
ple) 95% CI)
5.2.2 Emergency cards (history of 1 394 Odds Ratio (M-H, Random, 1.85 [1.14, 3.03]
prior SH) 95% CI)
5.2.3 Emergency cards (no history of 1 427 Odds Ratio (M-H, Random, 0.64 [0.34, 1.22]
prior SH) 95% CI)

Informed decisions.
Analysis 5.1. Comparison 5: Remote contact interventions:

Emergency cards, Outcome 1: Repetition of SH at post-intervention
Remote contact Comparator Odds Ratio Odds Ratio Risk of Bias

Evans 1999a 90 417 77 410 63.2% 1.19 [0.85 , 1.67] + + + + ? ?

Morgan 1993 5 101 12 111 36.8% 0.43 [0.15 , 1.27] ? + + + ? ?
Total (95% CI) 518 521 100.0% 0.82 [0.31 , 2.14]

Total events: 95 89
Test for overall effect: Z = 0.41 (P = 0.68) Favours remote contact Favours comparator
Risk of bias legend


Emergency cards, Outcome 2: Repetition of SH at 12 months
Remote contact Comparator Odds Ratio Odds Ratio

5.2.1 Emergency cards (whole sample)

Evans 1999a 90 417 77 410 100.0% 1.19 [0.85 , 1.67]
Subtotal (95% CI) 417 410 100.0% 1.19 [0.85 , 1.67]
Total events: 90 77
5.2.2 Emergency cards (history of prior SH)

Evans 1999a 52 194 33 200 100.0% 1.85 [1.14 , 3.03]
Subtotal (95% CI) 194 200 100.0% 1.85 [1.14 , 3.03]
Total events: 52 33
5.2.3 Emergency cards (no history of prior SH)

Evans 1999a 18 221 25 206 100.0% 0.64 [0.34 , 1.22]
Subtotal (95% CI) 221 206 100.0% 0.64 [0.34 , 1.22]
Total events: 18 25
Test for subgroup differences: Chi² = 6.70, df = 2 (P = 0.04), I² = 70.2% 0.1 0.2 0.5 1 2 5 10
Favours remote contact Favours comparator

Informed decisions.
Comparison 6. Remote contact interventions: Postcards
pants
6.1 Repetition of SH at post-in- 4 Odds Ratio (M-H, Random, 95% CI) Subtotals only
tervention
6.1.1 Postcards (whole sam- 4 3277 Odds Ratio (M-H, Random, 95% CI) 0.87 [0.62, 1.23]
ple)
6.1.2 Postcards (males) 1 247 Odds Ratio (M-H, Random, 95% CI) 0.86 [0.42, 1.75]
6.1.3 Postcards (females) 1 524 Odds Ratio (M-H, Random, 95% CI) 0.89 [0.56, 1.41]
6.2 Repetition of SH at 12 2 Odds Ratio (M-H, Random, 95% CI) Subtotals only
months
ple)
6.2.2 Postcards (males) 1 247 Odds Ratio (M-H, Random, 95% CI) 0.95 [0.50, 1.84]
6.2.3 Postcards (females) 1 524 Odds Ratio (M-H, Random, 95% CI) 1.19 [0.78, 1.80]
6.3 Frequency of SH at post-in- 3 Mean Difference (IV, Random, 95% Subtotals only
tervention CI)
6.3.1 Postcards (whole sam- 3 1097 Mean Difference (IV, Random, 95% -0.07 [-0.32, 0.18]
ple) CI)
6.3.2 Postcards (males) 3 401 Mean Difference (IV, Random, 95% -0.01 [-0.13, 0.12]
CI)
6.3.3 Postcards (females) 3 695 Mean Difference (IV, Random, 95% -0.04 [-0.29, 0.20]
CI)
6.3.4 Postcards (history of pri- 3 339 Mean Difference (IV, Random, 95% -0.09 [-0.68, 0.51]
or SH) CI)
6.3.5 Postcards (no history of 3 758 Mean Difference (IV, Random, 95% 0.23 [-0.32, 0.77]
prior SH) CI)
6.4 Frequency of SH at 12 2 Mean Difference (IV, Random, 95% Subtotals only

months CI)
ple) CI)
6.4.2 Postcards (males) 2 336 Mean Difference (IV, Random, 95% 0.03 [-0.11, 0.16]
CI)
CI)
or SH) CI)

Informed decisions.
pants
6.4.5 Postcards (no history of 2 688 Mean Difference (IV, Random, 95% -0.07 [-0.22, 0.09]
prior SH) CI)
6.5 Frequency of SH at 24 1 Mean Difference (IV, Random, 95% Subtotals only

months CI)
ple) CI)
6.5.2 Postcards (males) 1 220 Mean Difference (IV, Random, 95% 0.04 [-0.21, 0.29]
CI)
CI)
or SH) CI)
6.5.5 Postcards (no history of 1 134 Mean Difference (IV, Random, 95% -0.01 [-0.16, 0.14]
prior SH) CI)
6.6 Suicide deaths at post-in- 4 3464 Odds Ratio (M-H, Random, 95% CI) 1.86 [0.61, 5.72]
tervention
ple)

Informed decisions.

Postcards, Outcome 1: Repetition of SH at post-intervention
Remote contact Comparator Odds Ratio Odds Ratio Risk of Bias
6.1.1 Postcards (whole sample)

Beautrais 2010 39 153 49 174 25.5% 0.87 [0.53 , 1.43] + + + + ? ?
Carter 2005 57 378 68 394 31.9% 0.85 [0.58 , 1.25] ? - + + ? -
Hassanian-Moghaddam 2011 69 1043 99 1070 36.3% 0.69 [0.50 , 0.96] + + + ? ? ?
Kapur 2013 11 33 4 32 6.4% 3.50 [0.98 , 12.50] ? + + + ? ?
Subtotal (95% CI) 1607 1670 100.0% 0.87 [0.62 , 1.23]
6.1.2 Postcards (males)

Carter 2005 20 145 16 102 100.0% 0.86 [0.42 , 1.75] ? - + + ? -
Subtotal (95% CI) 145 102 100.0% 0.86 [0.42 , 1.75]
Total events: 20 16
6.1.3 Postcards (females)

Carter 2005 37 233 51 291 100.0% 0.89 [0.56 , 1.41] ? - + + ? -
Subtotal (95% CI) 233 291 100.0% 0.89 [0.56 , 1.41]
Total events: 37 51
0.1 0.2 0.5 1 2 5 10

Risk of bias legend Favours remote contact Favours comparator

Informed decisions.
Analysis 6.2. Comparison 6: Remote contact interventions: Postcards, Outcome 2: Repetition of SH at 12 months


Carter 2005 80 378 90 394 42.9% 0.91 [0.64 , 1.28]
Hassanian-Moghaddam 2011 114 1043 166 1070 57.1% 0.67 [0.52 , 0.86]
Subtotal (95% CI) 1421 1464 100.0% 0.76 [0.57 , 1.02]

Carter 2005 26 145 19 102 100.0% 0.95 [0.50 , 1.84]
Subtotal (95% CI) 145 102 100.0% 0.95 [0.50 , 1.84]
Total events: 26 19

Carter 2005 54 233 59 291 100.0% 1.19 [0.78 , 1.80]
Subtotal (95% CI) 233 291 100.0% 1.19 [0.78 , 1.80]
Total events: 54 59
0.1 0.2 0.5 1 2 5 10


Informed decisions.

Postcards, Outcome 3: Frequency of SH at post-intervention
Remote contact Comparator Mean Difference Mean Difference

Carter 2005 0.267 0.898 378 0.49 1.985 394 42.5% -0.22 [-0.44 , -0.01]
Hassanian-Moghaddam 2011 0.11 0.53 119 0.13 0.49 141 53.8% -0.02 [-0.14 , 0.10]
Kapur 2013 1.24 3.67 33 0.22 0.66 32 3.6% 1.02 [-0.25 , 2.29]
Subtotal (95% CI) 530 567 100.0% -0.07 [-0.32 , 0.18]

Carter 2005 0.2 0.56 145 0.21 0.569 102 73.6% -0.01 [-0.15 , 0.13]
Kapur 2013 2.64 6.02 11 0.33 0.89 12 0.1% 2.31 [-1.28 , 5.90]
Subtotal (95% CI) 219 182 100.0% -0.01 [-0.13 , 0.12]

Carter 2005 0.309 1.054 233 0.57 2.263 291 33.3% -0.26 [-0.55 , 0.03]
Kapur 2013 0.55 1.34 22 0.15 0.49 20 13.3% 0.40 [-0.20 , 1.00]
Subtotal (95% CI) 311 384 100.0% -0.04 [-0.29 , 0.20]
6.3.4 Postcards (history of prior SH)

Carter 2005 0.571 1.748 63 1.12 2.634 66 31.2% -0.55 [-1.32 , 0.22]
Kapur 2013 1.82 4.41 22 0.36 0.86 17 8.6% 1.46 [-0.43 , 3.35]
Subtotal (95% CI) 160 179 100.0% -0.09 [-0.68 , 0.51]
6.3.5 Postcards (no history of prior SH)

Carter 2005 0.206 0.585 315 0.36 1.805 328 33.2% -0.15 [-0.36 , 0.05]
Hassanian-Moghaddam 2011 0.07 0.41 44 0.06 0.3 45 33.9% 0.01 [-0.14 , 0.16]
Kapur 2013 0.91 0.3 11 0.07 0.26 15 32.9% 0.84 [0.62 , 1.06]
Subtotal (95% CI) 370 388 100.0% 0.23 [-0.32 , 0.77]
Heterogeneity: Tau² = 0.22; Chi² = 49.25, df = 2 (P < 0.00001); I² = 96%
-1 -0.5 0 0.5 1

Informed decisions.
Analysis 6.4. Comparison 6: Remote contact interventions: Postcards, Outcome 4: Frequency of SH at 12 months

Carter 2005 0.38 1.077 378 0.79 2.739 394 44.1% -0.41 [-0.70 , -0.12]
Subtotal (95% CI) 476 508 100.0% -0.19 [-0.58 , 0.20]

Carter 2005 0.28 0.768 145 0.28 0.788 102 50.0% 0.00 [-0.20 , 0.20]
Subtotal (95% CI) 198 138 100.0% 0.03 [-0.11 , 0.16]

Carter 2005 0.45 1.228 233 0.92 3.054 291 40.3% -0.47 [-0.85 , -0.09]
Subtotal (95% CI) 278 369 100.0% -0.22 [-0.62 , 0.18]

Carter 2005 0.84 2.026 63 2.36 4.796 66 40.9% -1.52 [-2.78 , -0.26]
Subtotal (95% CI) 143 153 100.0% -0.64 [-2.07 , 0.80]

Carter 2005 0.29 0.73 315 0.47 1.96 328 33.6% -0.18 [-0.41 , 0.05]
Subtotal (95% CI) 333 355 100.0% -0.07 [-0.22 , 0.09]
-1 -0.5 0 0.5 1

Informed decisions.
Analysis 6.5. Comparison 6: Remote contact interventions: Postcards, Outcome 5: Frequency of SH at 24 months

Subtotal (95% CI) 217 255 100.0% -0.03 [-0.16 , 0.10]

Subtotal (95% CI) 116 104 100.0% 0.04 [-0.21 , 0.29]

Subtotal (95% CI) 101 151 100.0% -0.07 [-0.21 , 0.07]

Subtotal (95% CI) 155 183 100.0% -0.09 [-0.31 , 0.13]

Subtotal (95% CI) 62 72 100.0% -0.01 [-0.16 , 0.14]
-1 -0.5 0 0.5 1

Postcards, Outcome 6: Suicide deaths at post-intervention


Beautrais 2010 2 153 0 174 12.7% 5.76 [0.27 , 120.90]
Carter 2005 2 378 4 394 35.6% 0.52 [0.09 , 2.85]
Hassanian-Moghaddam 2011 7 1150 2 1150 40.4% 3.52 [0.73 , 16.96]
Kapur 2013 1 33 0 32 11.3% 3.00 [0.12 , 76.40]
Subtotal (95% CI) 1714 1750 100.0% 1.86 [0.61 , 5.72]
Total events: 12 6
Total (95% CI) 1714 1750 100.0% 1.86 [0.61 , 5.72]

Total events: 12 6
Test for overall effect: Z = 1.08 (P = 0.28) Favours remote contact Favours comparator

Informed decisions.
Comparison 7. Remote contact interventions: Telephone-based psychotherapy
pants
7.1 Repetition of SH at post-interven- 2 185 Odds Ratio (M-H, Random, 0.36 [0.01, 8.94]
tion 95% CI)
7.2 Depression scores at post-inter- 2 185 Std. Mean Difference (IV, Ran- -0.40 [-1.39, 0.59]
vention dom, 95% CI)
7.3 Suicide deaths at post-interven- 3 240 Odds Ratio (M-H, Random, 3.09 [0.12, 78.55]
tion 95% CI)
Analysis 7.1. Comparison 7: Remote contact interventions: Telephone-

based psychotherapy, Outcome 1: Repetition of SH at post-intervention
Telephone Comparator Odds Ratio Odds Ratio Risk of Bias

Marasinghe 2012 0 34 0 34 Not estimable ? + + + ? ?

Wei 2013 0 56 1 61 100.0% 0.36 [0.01 , 8.94] ? + - ? ? -
Total (95% CI) 90 95 100.0% 0.36 [0.01 , 8.94]

Total events: 0 1
Test for overall effect: Z = 0.63 (P = 0.53) Favours telephone Favours comparator
Risk of bias legend


based psychotherapy, Outcome 2: Depression scores at post-intervention
Telephone Comparator Std. Mean Difference Std. Mean Difference

Marasinghe 2012 7 5 34 14.6 10.4 34 48.5% -0.92 [-1.42 , -0.42]

Wei 2013 7.92 9.26 56 7.14 8.33 61 51.5% 0.09 [-0.27 , 0.45]
Total (95% CI) 90 95 100.0% -0.40 [-1.39 , 0.59]

Test for subgroup differences: Not applicable Favours telephone Favours comparator

Informed decisions.

based psychotherapy, Outcome 3: Suicide deaths at post-intervention
Telephone Comparator Odds Ratio Odds Ratio

Marasinghe 2012 1 34 0 34 100.0% 3.09 [0.12 , 78.55]

Sreedaran 2020 0 8 0 7 Not estimable
Wei 2013 0 80 0 77 Not estimable
Total (95% CI) 122 118 100.0% 3.09 [0.12 , 78.55]

Total events: 1 0
Test for overall effect: Z = 0.68 (P = 0.49) Favours telephone Favours comparator
Comparison 8. Provision of information and support
pants
8.1 Repetition of SH at post-intervention 2 1853 Odds Ratio (M-H, Random, 1.09 [0.79, 1.50]
95% CI)
8.2 Suicide deaths at post-intervention 3 2577 Odds Ratio (M-H, Random, 0.15 [0.05, 0.48]
95% CI)
8.2.1 Provision of information and sup- 2 1889 Odds Ratio (M-H, Random, 0.12 [0.03, 0.44]
port 95% CI)
8.2.2 Provision of information and sup- 1 688 Odds Ratio (M-H, Random, 0.33 [0.03, 3.20]
port with peer support 95% CI)
Analysis 8.1. Comparison 8: Provision of information and support, Outcome 1: Repetition of SH at post-intervention
Mixed intervention Comparator Odds Ratio Odds Ratio Risk of Bias
Amadéo 2015 24 90 21 100 22.7% 1.37 [0.70 , 2.68] ? + + + ? ?

Fleischmann 2008 66 863 60 800 77.3% 1.02 [0.71 , 1.47] + ? - + ? -
Total (95% CI) 953 900 100.0% 1.09 [0.79 , 1.50]

Total events: 90 81
Test for overall effect: Z = 0.54 (P = 0.59) Favours mixed Favours comparator
Risk of bias legend


Informed decisions.
Analysis 8.2. Comparison 8: Provision of information and support, Outcome 2: Suicide deaths at post-intervention
Mixed intervention Comparator Odds Ratio Odds Ratio

8.2.1 Provision of information and support

Amadéo 2015 0 90 2 100 14.0% 0.22 [0.01 , 4.60]
Fleischmann 2008 2 872 18 827 60.7% 0.10 [0.02 , 0.45]
Subtotal (95% CI) 962 927 74.7% 0.12 [0.03 , 0.44]
Total events: 2 20
8.2.2 Provision of information and support with peer support

Naidoo 2014 1 344 3 344 25.3% 0.33 [0.03 , 3.20]
Subtotal (95% CI) 344 344 25.3% 0.33 [0.03 , 3.20]
Total events: 1 3
Total (95% CI) 1306 1271 100.0% 0.15 [0.05 , 0.48]

Total events: 3 23
Test for overall effect: Z = 3.21 (P = 0.001) Favours mixed Favours comparator
Comparison 9. Other multimodal interventions
pants
9.1 Repetition of SH at post-in- 3 Odds Ratio (M-H, Random, 95% Subtotals only
tervention CI)
9.1.1 Whole sample 3 1937 Odds Ratio (M-H, Random, 95% 0.69 [0.37, 1.30]
CI)
9.1.2 First SH episode 2 901 Odds Ratio (M-H, Random, 95% 1.02 [0.70, 1.47]
CI)
9.1.3 Repeat SH episode 2 938 Odds Ratio (M-H, Random, 95% 0.92 [0.52, 1.62]
CI)
9.2 Time to SH repetition 2 Hazard Ratio (IV, Random, 95% 0.39 [0.09, 1.76]
CI)
9.3 Depression scores at post-in- 3 651 Mean Difference (IV, Random, -0.52 [-2.08, 1.05]
tervention 95% CI)
9.4 Hopelessness scores at post- 2 556 Mean Difference (IV, Random, -0.29 [-1.27, 0.69]
intervention 95% CI)
9.5 Suicide deaths at post-inter- 3 971 Odds Ratio (M-H, Random, 95% 0.63 [0.13, 3.06]
vention CI)

Informed decisions.
Analysis 9.1. Comparison 9: Other multimodal interventions, Outcome 1: Repetition of SH at post-intervention

Mixed multimodal Comparator Odds Ratio Odds Ratio Risk of Bias
9.1.1 Whole sample

Gysin-Maillart 2016 5 55 16 43 18.9% 0.17 [0.06 , 0.51] + + + + + +
Hatcher 2015 142 737 135 737 42.6% 1.06 [0.82 , 1.38] + + + + + +
Hatcher 2016 85 182 92 183 38.5% 0.87 [0.57 , 1.31] ? + + + + ?
Subtotal (95% CI) 974 963 100.0% 0.69 [0.37 , 1.30]
9.1.2 First SH episode

Hatcher 2015 39 369 40 359 62.3% 0.94 [0.59 , 1.50] + + + + + +
Hatcher 2016 38 81 40 92 37.7% 1.15 [0.63 , 2.09] ? + + + + ?
Subtotal (95% CI) 450 451 100.0% 1.02 [0.70 , 1.47]
Total events: 77 80
9.1.3 Repeat SH episode

Hatcher 2015 104 368 95 378 58.3% 1.17 [0.85 , 1.62] + + + + + +
Hatcher 2016 47 101 52 91 41.7% 0.65 [0.37 , 1.15] ? + + + + ?
Subtotal (95% CI) 469 469 100.0% 0.92 [0.52 , 1.62]
Test for subgroup differences: Chi² = 1.05, df = 2 (P = 0.59), I² = 0% 0.1 0.2 0.5 1 2 5 10
Favours mixed multimodal Favours comparator
Risk of bias legend
Analysis 9.2. Comparison 9: Other multimodal interventions, Outcome 2: Time to SH repetition
Hazard Ratio Hazard Ratio

Study or Subgroup log[Hazard Ratio] SE Weight IV, Random, 95% CI IV, Random, 95% CI
Gysin-Maillart 2016 -1.77 0.48 45.9% 0.17 [0.07 , 0.44]

Hatcher 2016 -0.23 0.19 54.1% 0.79 [0.55 , 1.15]
Total (95% CI) 100.0% 0.39 [0.09 , 1.76]

Test for overall effect: Z = 1.22 (P = 0.22) 0.01 0.1 1 10 100
Test for subgroup differences: Not applicable Favours multimodal Favours comparator

Informed decisions.
Analysis 9.3. Comparison 9: Other multimodal interventions, Outcome 3: Depression scores at post-intervention
Mixed multimodal Comparator Mean Difference Mean Difference

Gysin-Maillart 2016 6.54 9.98 54 10.63 9.75 38 11.8% -4.09 [-8.18 , -0.00]
Hatcher 2015 6.8 4.9 211 6.5 5.1 234 51.0% 0.30 [-0.63 , 1.23]
Hatcher 2016 5.8 4.5 66 6.3 4.3 48 37.1% -0.50 [-2.13 , 1.13]
Total (95% CI) 331 320 100.0% -0.52 [-2.08 , 1.05]

Test for subgroup differences: Not applicable Favours mixed multimodal Favours comparator
Analysis 9.4. Comparison 9: Other multimodal interventions, Outcome 4: Hopelessness scores at post-intervention
Mixed multimodal Comparator Mean Difference Mean Difference

Hatcher 2015 8.3 6.3 210 8.4 6.4 233 68.2% -0.10 [-1.28 , 1.08]
Hatcher 2016 5 4.4 66 5.7 4.8 47 31.8% -0.70 [-2.43 , 1.03]
Total (95% CI) 276 280 100.0% -0.29 [-1.27 , 0.69]

Test for subgroup differences: Not applicable Favours mixed multimodal Favours comparator
Analysis 9.5. Comparison 9: Other multimodal interventions, Outcome 5: Suicide deaths at post-intervention
Mixed multimodal Comparator Odds Ratio Odds Ratio

Gysin-Maillart 2016 1 60 1 60 32.2% 1.00 [0.06 , 16.37]

Hatcher 2015 1 327 2 357 43.5% 0.54 [0.05 , 6.03]
Hatcher 2016 0 72 1 95 24.3% 0.43 [0.02 , 10.82]
Total (95% CI) 459 512 100.0% 0.63 [0.13 , 3.06]

Total events: 2 4
Test for overall effect: Z = 0.58 (P = 0.56) Favours mixed multimodal Favours comparator
ADDITIONAL TABLES
Table 1. Methods used at the index episode of self-harm

Reference Method
Self-poisoning Self-injury Combined self- Unspecified

poisoning and
n (%) n (%) self-injury n (%)
n (%)
Allard 1992 - - - -
Amadéo 2015 - - - -

Informed decisions.
Table 1. Methods used at the index episode of self-harm (Continued)
Andreoli 2015 - - - -
Armitage 2016 - - - -
Bateman 2009 - - - -
Beautrais 2010 1 250 (76.7) 64 (19.6) - 15 (4.6)
Bennewith 2002 7,733 (89.7) 158 (8.2) - 41 (2.1)
Brown 2005 70 (58.3) 33 (27.5) - 17 (14.2)
Carter 2005 772 (100) - - -
Cedereke 2002 - - - -
Clarke 2002 1 442 (94.6) 25 (5.3) 8 (1.70) -
Crawford 2010 74 (71.8) 25 (24.3) - 4 (3.9)
Davidson 2014 - - - -
Dubois 1999 - - - -
Evans 1999a 808 (97.7) - - 19 (2.3)
Evans 1999b - - - -
Fleischmann 2008 - - - -
Gibbons 1978 400 (100) - - -
Gratz 2006 - - - -
Gratz 2014 - - - -
Grimholt 2015 149 (100) - - -
Guthrie 2001 119 (100) - - -
Gysin-Maillart 2016 - - - -
Harned 2014 - 26 (100) - -
Hassanian-Moghaddam 2011 2,300 (100) - - -
Hatcher 2011 471 (85.3) 81 (14.7) - -
Hatcher 2015 532 (77.8) 125 (18.3) 27 (3.9) -
Hatcher 2016 115 (68.9) 41 (24.5) 11 (6.6) -
Hawton 1981 96 (100) - - -
Hawton 1987 80 (100) - - -

Informed decisions.
Husain 2014 217 (98.2) 4 (1.8) - -
Hvid 2011 - - - -
Kapur 2013 - - - -
Kawanishi 2014 1 707 (77.3) 332 (36.3) - 42 (4.6)
Liberman 1981 - - - -
Lin 2020 - - - -
Linehan 1991 - - - -
Linehan 2006 - - - -
Linehan 2015 - - - -
Marasinghe 2012 - - - -
McAuliffe 2014 2 161 (37.2) 57 (13.2) - 4 (0.9)
McLeavey 1994 39 (100) - - -
McMain 2009 - - - -
McMain 2017 - - - -
Morgan 1993 207 (97.6) - - 5 (2.4)
Morthorst 2012 - - - -
Mouaffak 2015 3 - - - -
Mousavi 2015 55 (100) - - -
Mousavi 2017 - - - -
Naidoo 2014 - - - -
O'Connor 2015 - - - -
O'Connor 2017 504 (97.3) - - 14 (2.7)
O'Connor 2020 - - - -
Owens 2020 40 (64.6) 12 (19.3) 10 (16.1) -
Patsiokas 1985 - - - -
Priebe 2012 - - - -
Sahin 2018 - - - -
Salkovskis 1990 - - - -

Informed decisions.
Slee 2008 73 (89.0) - - -
Sreedaran 2020 - - - -
Stewart 2009 - - - -
Tapolaa 2010 - - - -
Torhorst 1987 141 (100) - - -
Torhorst 1988 80 (100) - - -
Turner 2000 - - - -
Tyrer 2003 - - - -
Vaiva 2006 605 (100) - - -
Vaiva 2018 926 (93.8) - - -
Van der Sande 1997 232 (84.7) - - 42 (15.3)
Van Heeringen 1995 463 (89.7) - - 53 (10.3)
Walton 2020 - - - -
Wang 2016 4 - - - -
Waterhouse 1990 77 (100) - - -
Wei 2013 - - - -
Weinberg 2006 - - - -
Welu 1977 - 120 (100) - -
1 Percentages greater than 100% as participants could have used multiple methods.
2 Methods of self-harm for the remaining 221 (48.7%) participants were not reported.
3 The majority of participants engaged in 'non-violent' methods (n = 258; 85.2%), followed by 'violent' methods (n = 45; 14.8%). The methods
considered to be 'non-violent' or 'violent' in this trial were not reported, however.
4 The majority of participants engaged in 'low lethality' methods (n = 57; 89.1%), followed by 'high lethality' methods, including hanging,
charcoal burning, or jumping from a height (n = 7; 10.9%). The methods considered to be 'low lethality' in this trial were not reported,
however.
APPENDICES
Appendix 1. Cochrane Common Mental Disorders Specialised Register

The Cochrane Common Mental Disorders Group (CCMD) maintains an archived controlled trials register known as the CCMDCTR. This
specialised register contains over 40,000 reference records (reports of RCTs) for anxiety disorders, depression, bipolar disorder, eating
disorders, self-harm, and other mental disorders within the scope of this Group. The CCMDCTR is a partially studies-based register with
more than 50% of reference records tagged to around 12,500 individually PICO-coded study records. Reports of studies for inclusion in
the register were collated from (weekly) generic searches of key bibliographic databases to June 2016, which included: MEDLINE (1950
onwards), Embase (1974 onwards), PsycINFO (1967 onwards), quarterly searches of the Cochrane Central Register of Controlled Trials
(CENTRAL), and review-specific searches of additional databases. Reports of studies were also sourced from international trials registries,

Informed decisions.
drug companies, the handsearching of key journals, conference proceedings and other (non-Cochrane) systematic reviews and meta-
analyses. Details of CCMD's core search strategies (used to identify RCTs) are on the Group's website, with an example of the core MEDLINE
search displayed below.
[MeSH Headings]: eating disorders/ or anorexia nervosa/ or binge-eating disorder/ or bulimia nervosa/ or female athlete triad syndrome/
or pica/ or hyperphagia/ or bulimia/ or self-injurious behavior/ or self mutilation/ or suicide/ or suicidal ideation/ or suicide, attempted/
or mood disorders/ or affective disorders, psychotic/ or bipolar disorder/ or cyclothymic disorder/ or depressive disorder/ or depression,
postpartum/ or depressive disorder, major/ or depressive disorder, treatment-resistant/ or dysthymic disorder/ or seasonal affective
disorder/ or neurotic disorders/ or depression/ or adjustment disorders/ or exp antidepressive agents/ or anxiety disorders/ or
agoraphobia/ or neurocirculatory asthenia/ or obsessive-compulsive disorder/ or obsessive hoarding/ or panic disorder/ or phobic
disorders/ or stress disorders, traumatic/ or combat disorders/ or stress disorders, post-traumatic/ or stress disorders, traumatic, acute/
or anxiety/ or anxiety, castration/ or koro/ or anxiety, separation/ or panic/ or exp anti-anxiety agents/ or somatoform disorders/ or body
dysmorphic disorders/ or conversion disorder/ or hypochondriasis/ or neurasthenia/ or hysteria/ or munchausen syndrome by proxy/ or
munchausen syndrome/ or fatigue syndrome, chronic/ or obsessive behavior/ or compulsive behavior/ or behavior, addictive/ or impulse
control disorders/ or firesetting behavior/ or gambling/ or trichotillomania/ or stress, psychological/ or burnout, professional/ or sexual
dysfunctions, psychological/ or vaginismus/ or Anhedonia/ or Affective Symptoms/ or *Mental Disorders/ OR [Title/ Author Keywords]:
(eating disorder* or anorexia nervosa or bulimi* or binge eat* or (self adj (injur* or mutilat*)) or suicide* or suicidal or parasuicid* or
mood disorder* or affective disorder* or bipolar i or bipolar ii or (bipolar and (affective or disorder*)) or mania or manic or cyclothymic* or
depression or depressive or dysthymi* or neurotic or neurosis or adjustment disorder* or antidepress* or anxiety disorder* or agoraphobia
or obsess* or compulsi* or panic or phobi* or ptsd or posttrauma* or post trauma* or combat or somatoform or somati#ation or medical*
unexplained or body dysmorphi* or conversion disorder or hypochondria* or neurastheni* or hysteria or munchausen or chronic fatigue*
or gambling or trichotillomania or vaginismus or anhedoni* or affective symptoms or mental disorder* or mental health).tw,kf. AND [RCT
filter]: (controlled clinical trial.pt. or randomised controlled trial.pt. or (randomi#ed or randomi#ation).ab,ti. or randomly.ab. or (random*
adj3 (administ* or allocat* or assign* or class* or control* or determine* or divide* or distribut* or expose* or fashion or number* or place*
or recruit* or subsitut* or treat*)).ab. or placebo*.ab,ti. or drug therapy.fs. or trial.ab,ti. or groups.ab. or (control* adj3 (trial* or study or
studies)).ab,ti. or ((singl* or doubl* or tripl* or trebl*) adj3 (blind* or mask* or dummy*)).mp. or clinical trial, phase ii/ or clinical trial, phase
iii/ or clinical trial, phase iv/ or randomised controlled trial/ or pragmatic clinical trial/ or (quasi adj (experimental or random*)).ti,ab. or
((waitlist* or wait* list* or treatment as usual or TAU) adj3 (control or group)).ab.)
Records were screened for reports of RCTs within the scope of the Cochrane Common Mental Disorders Group. Secondary reports of RCTs
were tagged to the appropriate study record
An information specialist with CCMD will cross-search the CCMDCTR-Studies and References register using the following terms (all fields):
(suicid* or parasuicid* or "auto mutilat*" or automutilat* or "self destruct*" or selfdestruct* or self-harm* or selfharm* or "self immolat*"
or selfimmolat* or "self inflict*" or selfinflict* or "self injur*" or selfinjur* or selfmutilat* or "self mutilat*" or "self poison*" or selfpoison*
or (self adj2 (cut or cuts or cutting or cutter? or burn or burns or burning or bite or bites or biting or hit or hits or hitting)) or "head bang*"
or headbang* or "over dose*" or overdos* or NSSI* or nonsuicid* or non-suicid*) (2015-June-2016) n = 29
Appendix 2. MEDLINE, Embase, PsycINFO Ovid search strategy

An information specialist with CCMD searched the main biomedical databases using the terms listed below from January 2015 to 4-
July-2020. [N.B. CCMDCTR is current to June 2016 only]
Search summary
Date-of-search: 4-July-2020
• Cochrane Library (CDSR) Systematic Reviews, n = 38

• Cochrane Library (CDSR) Protocols, n = 12
• Cochrane Library CENTRAL, n = 2727
• Cochrane Specialised Register (CCMDCTR), n = 291
• Ovid MEDLINE, PsycINFO (cross-search), n = 2743
• Ovid Embase (precise), n = 1375
Total = 7186
Duplicates removed, n = 2483
To screen, n = 4703
[Cochrane Library CENTRAL-Trial Register Records (removed) n = 1969]
Cochrane Library (Issue 7 of 12, 2020) [Date limited, 2015 onwards]
#1 MeSH descriptor: [Self-Injurious Behavior] explode all trees
#2 (overdose* and prevent*):kw or (overdos* near/3 prevent*):ti,ab
#3 ((nonfatal or non-fatal) near/2 (overdose* or over dose*)):ti,ab,kw

Informed decisions.
#4 (NSSI* or ((nonsuicid* or non-suicid*) near/2 (self* or injur*))):ti,ab

#5 (suicid* or parasuicid* or (auto next mutilat*) or automutilat* or (self next destruct*) or selfdestruct* or self-harm* or selfharm* or (self
next harm*) or (self next immolat*) or selfimmolat* or (self next inflict*) or selfinflict* or (self next injur*) or selfinjur* or selfmutilat* or (self
next mutilat*) or (self next poison*) or selfpoison* or (self near/2 (cut or cuts or cutting or cutter* or burn or burns or burning or bite or
bites or biting or hit or hits or hitting)) or (head next bang*) or headbang*):ti,ab,kw
#6 (#1 or #2 or #3 or #4 or #5)
Limited 2015 to date
CDSR-reviews (38); CDSR-protocols (12); CENTRAL (2727); CENTRAL-TR (1969)
***************************
PsycINFO/MEDLINE cross-search
Ovid APA PsycInfo <1806 to June Week 5 2020>, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and
Daily <1946 to July 02, 2020> [Date limited, 2015 onwards]
Search Strategy:
--------------------------------------------------------------------------------
1 Automutilation/ or Self-injurious Behavior/ or Self-destructive Behavior/ or Self-mutilation/ or Self-inflicted Wounds/ (19601)
2 Suicidal Behavior/ or Suicide/ or Suicidal Ideation/ or Attempted Suicide/ or Suicide, Attempted/ or Self Poisoning/ or Suicide Prevention/
or Suicide Prevention Centers/ or Suicidology/ (97875)
3 (suicid* or parasuicid* or auto mutilat* or automutilat* or self destruct* or selfdestruct* or self-harm* or selfharm* or self immolat* or
selfimmolat* or self inflict* or selfinflict* or self injur* or selfinjur* or selfmutilat* or self mutilat* or self poison* or selfpoison* or (self
adj2 (cut or cuts or cutting or cutter? or burn or burns or burning or bite or bites or biting or hit or hits or hitting)) or head bang* or
headbang*).ti,ab,kf,kw,id. (164244)
4 (NSSI? or ((nonsuicid* or non-suicid*) adj2 (self* or injur*))).ti,ab,kf,kw,id. (3469)
5 (Overdose/ or Drug Overdose/ or Drug Overdoses/) and prevent*.af. (3529)
6 ((nonfatal or non-fatal) adj2 (overdose? or over dose?)).mp. (571)
7 or/1-6 (183505)
8 Randomized Controlled Trial/ (509272)
9 Randomized Controlled Trial.pt. (508805)
10 Randomization/ (103117)
11 Random Allocation/ (103117)
12 Controlled Clinical Trial/ (93744)
13 Controlled Clinical Trial.pt. (93744)
14 Double-blind Method/ or Single-blind Method/ (186347)
15 (randomi#ed or randomi#ation or randomi#ing).ti,ab,kf,kw,id. (726423)
16 (RCT or "at random" or (random* adj3 (administ* or allocat* or assign* or class* or cluster or crossover or cross-over or control* or
determine* or divide* or division or distribut* or expose* or fashion or number* or place* or pragmatic or quasi or recruit* or split or
subsitut* or treat*))).ti,ab,kf,kw,id. (667814)
17 trial.ti. (251482)
18 placebo/ or (placebo and (allocat* or assign* or control* or group*)).ti,ab,kf,kw,id. (204672)
19 (control* adj3 group*).ab. (634930)
20 (control* and (trial or study or group*) and (waitlist* or wait* list* or ((treatment or care) adj2 usual))).ti,ab,kf,kw,id. (32182)
21 ((single or double or triple or treble) adj2 (blind* or mask* or dummy)).ti,ab,kf,kw,id. (200109)
22 treatment effectiveness evaluation/ (24511)
23 or/8-22 (1833008)
24 7 and 23 (9906)
25 (2015* or 2016* or 2017* or 2018* or 2019* or 2020*).yr,dc,dp,dt,ep,ez. (7909383)
26 24 and 25 (3732)
27 remove duplicates from 26 (2743)
***************************
Ovid Embase <1974 to 2020 Week 26> [Date limited, 2015 onwards]
Search Strategy:
--------------------------------------------------------------------------------
1 Automutilation/ (17795)
2 suicidal behavior/ or self immolation/ or self poisoning/ or suicidal ideation/ or suicide/ or suicide attempt/ (101066)
3 Drug Overdose/ and prevent*.af. (4897)
4 (suicid* or parasuicid* or auto mutilat* or automutilat* or self destruct* or selfdestruct* or self-harm* or selfharm* or self immolat* or
selfimmolat* or self inflict* or selfinflict* or self injur* or selfinjur* or selfmutilat* or self mutilat* or self poison* or selfpoison* or (self
adj2 (cut or cuts or cutting or cutter? or burn or burns or burning or bite or bites or biting or hit or hits or hitting)) or head bang* or
headbang*).ti,kw. (62383)
5 (NSSI? or ((nonsuicid* or non-suicid*) adj2 (self* or injur*))).ti,ab,kw. (1786)
6 ((nonfatal or non-fatal) adj2 (overdose? or over dose?)).mp. (418)
7 or/1-6 (125188)

Informed decisions.
8 randomized controlled trial/ (608057)

9 randomization.de. (87068)
10 controlled clinical trial/ and (Disease Management or Drug Therapy or Prevention or Rehabilitation or Therapy).fs. (253859)
11 *clinical trial/ (17606)
12 placebo.de. (351476)
13 placebo.ti,ab. (307193)
14 trial.ti. (301646)
15 (randomi#ed or randomi#ation or randomi#ing).ti,ab,kw. (917476)
16 (RCT or "at random" or (random* adj3 (administ* or allocat* or assign* or class* or cluster or control* or crossover or cross-over or
determine* or divide* or division or distribut* or expose* or fashion or number* or place* or pragmatic or quasi or recruit* or split or
subsitut* or treat*))).ti,ab,kw. (769731)
17 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$ or dummy)).mp. (309225)
18 (control* and (study or group?) and (waitlist* or wait* list* or ((treatment or care) adj2 usual))).ti,ab,kw,hw. (39665)
19 or/8-18 (1732296)
20 ((animal or nonhuman) not (human and (animal or nonhuman))).de. (5683745)
21 19 not 20 (1575127)
22 7 and 21 (8502)
23 (2015* or 2016* or 2017* or 2018* or 2019* or 2020*).yr,dc,dp. (9329153)
24 22 and 23 (3277)
25 limit 24 to exclude medline journals (353)
26 *Automutilation/ (7770)
27 *suicidal behavior/ or *self immolation/ or *self poisoning/ or *suicidal ideation/ or *suicide/ or *suicide attempt/ (49956)
28 *Drug Overdose/ and prevent*.af. (984)
29 4 or 5 or 6 or 26 or 27 or 28 (72349)
30 21 and 29 (2692)
31 23 and 30 (1132)
32 25 or 31 (1375)
***************************
WHAT'S NEW
Date Event Description
21 April 2021 New citation required and conclusions A new protocol including updated methodology was applied
have changed (Witt 2020b). Twenty-one new studies were included in this re-
view compared to the earlier version (Hawton 2016).
21 April 2021 New search has been performed This review updates and replaces the Cochrane Review 'Psy-
chosocial interventions for self-harm in adults' (Hawton 2016).
HISTORY
Protocol first published: Issue 7, 2020
Review first published: Issue 4, 2021
Date Event Description
1 July 2020 New citation required and major We updated the protocol developed for Hawton 2016
changes
CONTRIBUTIONS OF AUTHORS
KH had the idea for the review. All authors screened studies for inclusion. KGW, SEH, GR, and KH extracted data and assessed risk of bias
for included studies. KGW, SEH, and TLTS conducted the statistical analyses. KGW and KH wrote the initial version of the review and all
authors contributed to the writing of drafts. All authors approved the final version of the review for publication.

Informed decisions.
DECLARATIONS OF INTEREST
KGW: is an editor for the Cochrane Common Mental Disorders Group, and senior editor for the Self-Harm and Suicide Satellite of the group.
SEH: is the joint co-ordinating editor of the Cochrane Common Mental Disorders Group. She is funded by an Auckland Medical Research
Foundation Douglas Goodfellow Repatriation Fellowship to develop and test a digital intervention for young people who engage in self-
harm. She is the Principal Clinical Advisor of the Suicide Prevention Office of the Ministry of Health for the New Zealand Government.
GR: no declarations of interest to report in relation to this review
PH: no declarations of interest to report in relation to this review
TLTS: no declarations of interest to report in relation to this review
ET: no declarations of interest to report in relation to this review
KH: no declarations of interest to report in relation to this review
SOURCES OF SUPPORT
Internal sources
• No sources of support supplied
External sources
• National Health and Medical Research Council, Australia
KW is supported by an Emerging Leadership 1 Fellowship awarded by the NHMRC (APP1177787).

• National Institute of Health Research (NIHR), UK
KW received support from the NIHR (Award number: NIHR 131986)
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Following consensus discussions with review authors, we combined one comparison with case management:
• Treatment adherence enhancement approaches.
We added three further comparisons to reflect approaches used in new trials of psychosocial interventions for SH in adults identified by
this update:
• Psychodynamic psychotherapy;
• Structured general practitioner (GP) follow-up;
• Brief emergency department-based interventions.
INDEX TERMS
Medical Subject Headings (MeSH)

*Cognitive Behavioral Therapy; Confidence Intervals; Depression [therapy]; *Dialectical Behavior Therapy; Mentalization; Problem
Solving; Psychosocial Intervention [*methods]; *Psychotherapy, Psychodynamic; Randomized Controlled Trials as Topic; Recurrence;
Secondary Prevention [methods]; Self-Injurious Behavior [psychology] [*therapy]; Suicide Prevention
MeSH check words

Adult; Female; Humans; Male


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Cochrane

Psychosocial interventions for self-harm in adults (Review)

Psychosocial interventions for self-harm in adults (Review)

Psychosocial interventions for self-harm in adults (Review) i

Psychosocial interventions for self-harm in adults (Review) ii

Psychosocial interventions for self-harm in adults

Contact: Katrina G Witt, katrina.witt@orygen.org.au.

Editorial group: Cochrane Common Mental Disorders Group.

Data collection and analysis

Psychosocial interventions for self-harm in adults (Review) 1

PLAIN LANGUAGE SUMMARY

Psychosocial interventions for adults who self-harm

Why is this review important?

Who will be interested in this review?

What questions does this review aim to answer?

Which studies were included in the review?

Psychosocial interventions for self-harm in adults (Review) 2

What does the evidence from the review tell us?

What should happen next?

Psychosocial interventions for self-harm in adults (Review) 3

Patient or population: self-harm in adults

GRADE Working Group grades of evidence

Cochrane Database of Systematic Reviews

Patient or population: self-harm in adults

GRADE Working Group grades of evidence

Cochrane Database of Systematic Reviews

Patient or population: self-harm in adults

Outcomes Anticipated absolute effects* Relative effect № of partici- Certainty of Comments

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Patient or population: self-harm in adults

Outcomes Anticipated absolute effects* Relative effect № of partici- Certainty of Comments

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Patient or population: self-harm in adults

Cochrane Database of Systematic Reviews

Comparison 3: MBT compared TAU or another comparator for self-harm in adults

Patient or population: self-harm in adults

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Patient or population: self-harm in adults

GRADE Working Group grades of evidence

Cochrane Database of Systematic Reviews

Psychodynamic psychotherapy compared to TAU or another comparator for self-harm in adults

Patient or population: self-harm in adults

GRADE Working Group grades of evidence

Case management compared to TAU or another comparator for self-harm in adults

Cochrane Database of Systematic Reviews

Patient or population: self-harm in adults

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Patient or population: self-harm in adults

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Patient or population: self-harm in adults

Cochrane Database of Systematic Reviews

GRADE Working Group grades of evidence

Patient or population: self-harm in adults