REVIEW Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis Dennis Ougrin, MBBS, MRCPsych, PGDip(Oxon), PhD, Troy Tranah, BSc, MSc, PhD, Daniel Stahl, PhD, Paul Moran, MBBS, BSc, MSc, DLSHTM, MD, MRCPsych, Joan Rosenbaum Asarnow, PhD Objective: Suicidal behavior and self-harm are common in adolescents and are associated with elevated psycho- pathology, risk of suicide, and demand for clinical ser- vices. Despite recent advances in the understanding and treatment of self-harm and links between self-harm and suicide and risk of suicide attempt, progress in reducing suicide death rates has been elusive, with no substantive reduction in suicide death rates over the past 60 years. Extending prior reviews of the literature on treatments for suicidal behavior and repetitive self-harm in youth, this article provides a meta-analysis of randomized controlled trials (RCTs) reporting efficacy of specific pharmacolog- ical, social, or psychological therapeutic interventions (TIs) in reducing both suicidal and nonsuicidal self-harm in adolescents. Method: Data sources were identified by searching the Cochrane, Medline, PsychINFO, EMBASE, and PubMed databases as of May 2014. RCTs comparing specific ther- apeutic interventions versus treatment as usual (TAU) or placebo in adolescents (through age 18 years) with self- harm were included. Results: Nineteen RCTs including 2,176 youth were analyzed. TIs included psychological and social inter- ventions and no pharmacological interventions. The proportion of the adolescents who self-harmed over the follow-up period was lower in the intervention groups (28%) than in controls (33%) (test for overall effect z ¼ 2.31; p ¼ .02). TIs with the largest effect sizes were dialectical behavior therapy (DBT), cognitive-behavioral therapy (CBT), and mentalization-based therapy (MBT). There were no independent replications of efficacy of any TI. The pooled risk difference between TIs and TAU for suicide attempts and nonsuicidal self-harm considered separately was not statistically significant. Conclusion: TIs to prevent self-harm appear to be effec- tive. Independent replication of the results achieved by DBT, MBT, and CBT is a research priority. Key Words: self-harm, randomized controlled trials, meta-analysis J Am Acad Child Adolesc Psychiatry 2015;54(2):97–107. S uicide is a global health problem and a major public health concern. 1,2 It is the second or the third leading cause of death in adolescents in the West and an important cause of death in developing countries. 2 In the United States, the research literature tends to distinguish between suicide attempts (defined as self-harm with some non-zero intent to die), non-suicidal self-injury (NSSI), and self-harm with undetermined intent. 3 In contrast, researchers in the United Kingdom and Europe frequently use the broader term “self-harm” to refer to self-poisoning or self- injury, irrespective of the intent. 4 Both suicide attempts and the broader self-harm category have been shown to be among the strongest predictors of death by suicide in adolescence, increasing the risk approximately 10-fold. 5,6 The critical need for clinical guidance regarding optimal clinical intervention strategies for youths engaging in self-harm is underscored by research indicating the following: prior suicide attempts and self-harm broadly are strong predictors of suicide deaths 5,7 ; among depressed ad- olescents and those at risk for depression, NSSI is a strong predictor of future suicide attempts 8-10 ; and a substantial subgroup of youths who attempt suicide also engage in NSSI. 9 Self-harm, defined broadly, is also a common phe- nomenon: a systematic review of 128 studies reported a pooled lifetime prevalence of 13.2% (95% CI ¼ 8.1–18.3). 11 Rates for self-harm (which include suicide attempts and NSSI) are higher than those for suicide attempts, currently estimated at an annual rate of 7.8%. 12 This review and meta-analysis seek to extend and update a number of previous notable reviews of suicidal behavior and self-harm in adolescents that did not include meta-an- alyses 6,13 and were specifically focused on suicidal behavior 7,14,15 ; non-suicidal self-harm only 16,17 ; social factors linked with self-harm 18 ; emergency management of self- harm 19 studies with mixed adult and adolescent samples 20 ; or the etiological factors of self-harm. 21 To our knowledge, this is the first published meta- analysis of randomized controlled trials (RCTs) evaluating therapeutic interventions (TIs) in reducing both suicidal behavior and nonsuicidal self-harm in adolescents. Clinical guidance is available at the end of this article. Supplemental material cited in this article is available online. JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY VOLUME 54 NUMBER 2 FEBRUARY 2015 www.jaacap.org 97