Family-based intervention for suicide prevention in adolescences: A systematic review

Nội dung text: Family-based intervention for suicide prevention in adolescences: A systematic review

1. RESEARCH ARTICLE FAMILY-BASED INTERVENTION FOR SUICIDE PREVENTION IN ADOLESCENCES: A SYSTEMATIC REVIEW Pham Thi Thu Huong1, Pham Thi Thu Hien2, Nguyen Thi Son1, Nguyen Thi My Ngoc2 1Hanoi Medical University 2Bach Mai Hospital ABSTRACT Aims: To examine the effectiveness significant reduction in suicide ideation, self- of Family-Based Intervention for suicide harm of the teenagers and no completed prevention in adolescences. Design: A suicide during the treatment and follow-up systematic review. Data sources: Search period. Conclusion: Overall all studies was performed in MEDLINE, Embase were conducted in high-income countries and Cochrane library. Method: Literature with refer from emergency departments search was performed during April to May and psychiatric hospitals. We identified that 2020 using inclusion and exclusion criteria. family-based interventions are powerful PRISMA guidelines were followed. Identified evidence to reduce suicidal ideation and records were reviewed by title, abstract and self-harm for adolescences. Implication: by the full text by main researcher then This study ensured rigorous methodology, made a quality assessment of the included followed PRISMA recommendations and studies. Included studies were extracted and evaluated quality of identified literature synthesized. Results: In total, 451 articles using Cochrane Risk of Bias Tool guidelines. were retrieved via database searching. A critical synthesis was performed to Following initial screening, 422 full-text produce a conceptualization of evidence. articles were screened, of which six met The synthesis represents effective family our inclusion criteria. The review therefore interventions for suicide prevention of includes findings from six studies which adolescence with suicide risk. were assessed as high quality. Five studies were RCTs and one study was RCTs trial Keywords: adolescence, suicide which delivered in both clinical setting and prevention, family caregiver, family participants’ home. All six studies reported intervention therapy 1. INTRODUCTION Suicide is global public health issue, cause of death in young people aged 15- accounted for 1.4% of all deaths worldwide, 29 years after traffic accidents, and the vast making it the 18th leading cause of death in majority (90%) were from low- and middle- 2016 (1). Suicide was the second leading income countries (1). The mean proportion of young people was reported in a systematic review of Evans et al., with 9.7% lifetime suicide attempt and 29.9% suicide thoughts Cor. author: Pham Thi Thu Huong (2). Suicide and suicide attempts affect Email: phamhuong@hmu.edu.vn not only the families and friends of those Received: Feb 08, 2021 who died, but also for people still survive. Revised: Feb 15, 2021 Nevertheless, the economic costs, social Accepted: Mar 05, 2021 costs and spiritual costs that one committed 98 Journal of Nursing Science - Vol. 04 - No. 01
2. RESEARCH ARTICLE suicide, attack the whole communities and its before discharge. In contrast, number of nation (3). An estimated of $93.5 billion have studies concentrated on reinforcement the been paid by suicide and suicide attempts health care networking around the patient in combination of medical costs, direct and as leading strategy but only rely on mental indirect costs as loss productivity in families health personnel and emergency services and individual in US during 2013 (4). (15, 16). Including caregivers in prevention There is strong evidence that strategies could strongly improve the family relationship takes an important comprehension regarding patients ‘suicide consideration in suicide risk. To be risk situation (17). It is important to illustrated, family factors such as conflict understand whether family-based therapies and poor communication, loss of caregiver, implications in suicide prevention strategy parent divorces, and psychopathology for young people, specifically whether there in first-degree relatives are risk factors are unintended consequences in term of for adolescent suicide; and adolescents’ management and prevention suicide risk deliberate self-harm are often precipitated for teenagers. by conflicts related to family environment Background (5, 6). Moreover, previous studies showed Suicidal ideations and behaviors which that lack of supportive adult relationships have defined as suicide attempt or self- was significant associated with adolescents’ harm with clear or unclear suicidal intent. depressive symptoms and suicidal ideation Reason to admit hospital by deliberate (7, 8). Several findings highlight the self-harm significantly predicts subsequent importance and benefit of relationship- suicide in adolescences, especially during focused treatments for teenagers who the period immediately following discharge perceived more negative family interactions from psychiatric inpatient treatment (8, 9). associated with highest risk for suicide (18, According to the literature, most of the 19). Suicide prevention programs have caregivers desire to help their children with approached in different strategies included severe suicidal ideation, however they inpatient settings, outpatient clinics, school lack of the competence in providing safe and home (19). Of the interest, researchers keeping and emotional support (10, 11). In have called attention to the important of fact, a few studies have involved caregivers caregiver role in reducing suicidal ideation in a suicide prevention approach. According and behavior and increasing treatment to Sun et al., caregivers were able to play adherence (11, 20, 21). Therefore, an important part in providing support and caregivers and healthcare providers detecting warning signs and are potential should strive to create a back-and-forth allies in suicide prevention (12, 13). dynamic which empower caregivers as Based on clinical observations of 13,000 well as reduce constant burden during suicidal adolescents and their families caring process (17). Family intervention in the emergency department, Wharff et might help both caregivers and teenagers al., found that “family connectedness” is stabilize and warrant careers’ competence one of the most salient protective factors to manage their children safely at home as against completed suicide (14). In this well as manage current and future crisis. perspective, caregiver involvement should Hence, the need for hospitalization due to be emphasized systematically for those suicide attempt or even fatal would reduce at suicide risk during hospitalization and significant (11). Despite the promising Journal of Nursing Science - Vol. 04 - No. 01 99
3. RESEARCH ARTICLE results, some evidences indicated the 2.3. Search methods problem in delivery the treatment and The search strategy was developed intervention for family caregivers of the and conducted following PICO framework young people at risk of suicide (19, 22). with the question: Which family-based Thus, there is a need for developing a interventions (I) are effective in reducing unique family-based model approach for suicide risk (O) of adolescence at risk of management and follow-up adolescences suicide (P)? with suicide thought and behaviors. To do The primary outcomes of interest were that it is important to explore existing family the reduction in suicide risk in adolescences. interventions and their effectiveness. The secondary outcomes of interest 2. RESEARCH METHOD were enhancing family relationship. 2.1. Aims The complete search strategy for This systematic review aimed to each database can be found in Table 1. examine the effectiveness of Family- A systematic search of Medline, Embase Based Intervention for suicide prevention in and Cochrane Library was conducted 1st adolescences. April to 10th May 2020 with the limiters of 2.2. Design English language studies. Time limiters This systematic review was planned, were applied from 2013 – 2020. Studies conducted and reported in April to May had to be peer-reviewed and published as 2020 according to the Preferred Reporting full-text: abstract only papers and opinion, Items for Systematic Reviews and Meta- discussion or review papers were excluded. analysis (PRISMA) Statement (23). Table 1. Search strategy Cochrance Other MEDLINE Embase Library sources Key words/ Databases 1 AND 2 AND 3 (suicidal ideation OR suicidal thought* OR suicide attempt* OR parasuicide OR suicidal behavi* 1 OR deliberate self-harm OR self- harm) (adolescen* OR teen* OR juvenile* 2 OR secondary school* OR youth*) (family-based intervention OR family 57 317 62 15 therapy OR family psychotherapy OR family intervention OR family treatment OR carer intervention 3 OR significant other intervention OR adult relative intervention OR close relative intervention OR close person intervention) Total 451 100 Journal of Nursing Science - Vol. 04 - No. 01
4. RESEARCH ARTICLE 2.4. Search outcome 3. RESULTS In total 451 citations were uploaded 3.1. Search results into Endnote X7 and after removal of duplicates, the search yielded 422 citations In total, 451 articles were retrieved via for screening. The researcher assessed database searching during the time limit titles and abstracts for eligibility using from 2013 - 2019. Following initial screening, the exclusion and inclusion criteria. The 422 full-text articles were screened, of Preferred Reporting Items for Systematic which six met our inclusion criteria. The Reviews and Meta-Analyses (PRISMA) review therefore includes findings from six (23) flow diagram shows the results of the studies (6, 8, 11, 26-28) (see Figure 1). search and screening processes (Figure 1). 3.2. Study characteristics 2.5. Quality appraisal All of included studies were randomized An assessment of study quality was controlled trials (RCTs) which conducted conducted. For all RCTs, this was assessed in three countries as United States (four based on the Cochrane Collaboration Risk studies), Australia (one study) and Ireland of Bias Tool (24). In the majority of trials, (one study). Studies were published as is often the case, blinding of participants between 2013 – 2019. The sample sizes and therapists was not possible (25). Each of six studies ranged from 35 (27) to 142 trial was therefore assessed with regard (11) adolescences with suicide risks and to random sequence generation, blinding their caregivers. Almost studies had both of participants and personnel, blinding of intervention groups and control groups, outcome assessment, ascertainment of one pilot study (27) did not have control deliberate self-harm, outcome assessor group. Three studies (50%) were provided blinding, whether analyses were conducted at participants’ houses which were decided according to the intention-to-treat (ITT) by participants’ preference (6, 26, 27). principle, and rates of attrition. For the latter The others were implemented at hospital criterion, an attrition rate of 15% or less on setting as mental health out-patient clinics, the primary outcome at the longest follow- pediatric emergency department and up point indicated low risk of bias. emergency departments (ED) (8, 11, 28). 2.6. Data abstraction Adolescence and their caregivers were recruited from ED and psychiatric hospitals. Data were extracted using a standardized Each study used different standard of data extraction form in Microsoft Excel adolescence age such as 12-17 (6); 11-17 included study: author, year, country, (28); 11-18 (26, 27); 12-18 (8) and 13-18 study design, population, intervention, (11), overall adolescent participants were comparison, outcomes, major findings from 11 – 18 years old. The majority of relevant to the PICO. Two reviewers adolescences were female (70% - 88.1%). checked the accuracy of the input data. All young people in review studies were recruited based on their suicide attempt, 2.7. Synthesis deliberate self-harm and suicide ideation A descriptive analysis of included at current state or within 72 hours to three studies is provided in the text narrative and months. Three studies had included criteria summarized in the PRISMA flow diagram for teenagers with cormorbid mental health (Figure 1). disorders as depression (6, 8, 28) or anxiety Journal of Nursing Science - Vol. 04 - No. 01 101
5. RESEARCH ARTICLE and posttraumatic stress disorder (6). Cognitive Behavior Therapy (AO-CBT), Caregivers, who were recruited in review Family-enhanced Nondirective Supportive studies, were defined coherently as parents Therapy (FE-NST). Please see Table 1. (biological or adoptive), primary career 3.3. Intervention programs content (6), primary caretaking parent, caregivers Overall, doses of family psychoeducation – hereafter referred to as parents (26), treatment in review studies vary from four primary caregiver other than mother or to twenty sessions within one to two hours father as aunt, grandmother, step mother, per session in the duration of four to sixteen older sibling (8), caregivers, legal guardian weeks, only one study provided one single with whom the adolescent resided (11). session. However, the most common and important for caregivers that they had to live together RAP-P intervention program was and supported for teenagers with suicide delivered for parents of young adults risk during the intervention and follow-up. through four sessions during 4-8 weeks One study conducted by Spirito et al., (28) with two hours each session. The provided intervention for both parents and intervention was mainly focus on stress their children who got diagnosed together management, adolescent development, with major depressive disorders. strategies to promote family harmony and to manage conflict, information to Studies examined the impact of range enhance parents understanding of suicidal of interventions, including individual (for behavior and practical strategies to help only parent and adolescence) or both their children minimize their self-injurious adolescence and their caregiver in conjoint behavior (6). SAFETY Program included sessions. Intervention programs which 20 session over 12 weeks with 9 weeks were delivered for both adolescences and individual intervention for caregivers and caregivers together were Resourceful Adolescent Parent Program (RAP-P), children, then 3 final week brought youths, Family-Based Crisis Intervention (FCBI). parents and therapists together to practice Safe Alternatives for Teens & Youths safety skills and behavior skills. SAFETY (SAFETY Program) and Attachment-based Program’s contents were psychoeducation, Family Therapy (ABFT) were decorated to identify youth and family strengths, delivery separate parents and adolescence emotional thermometer, “safety plan” for mostly sessions then therapists worked with reducing “emotional temperature” and both parents and teens in final sessions. suicide attempt risk and “Safety Plan Card” Only Parent-Adolescent-Cognitive (26, 27). Two studies assessed at the same Behavior Therapy (PA-CBT) was delivered time points: baseline-assessments after separately during the intervention program, ED-discharge, 3-month post-treatment however all individual sessions concluded assessments, and at 6-months, but in with a conjoint meeting between parent and studied conducted in 2017 Asarnow et al., teen to enhance positive communication added one more time point to measure the and a review of the skills learned. Control effectiveness at 12 month postbaseline conditions included treatment as usual (26). (TAU) e.g. routine care, enhanced TAU e.g. To enhance family functioning in term an in-clinic parent education session, follow of support teen reduce suicide risk and by at least 3 telephone calls supporting understand from adolescences’ point of motivation or active control group with other view about different treatments, researchers intervention program as Adolescent Only delivered ABFT and FE-NST during 16 102 Journal of Nursing Science - Vol. 04 - No. 01
6. RESEARCH ARTICLE weeks (8). Both treatments shared a (6 weeks), end of treatment (12 weeks), common goal of improving the adolescent’s and 48 weeks follow-up. ability to rely on adult support for managing Difference with other interventions were suicidal and depressive symptoms. ABFT delivered from four weeks to 12 weeks, primarily relies on joint parent–teen FBCI was a novel, single-session ED-based sessions that address the rupture and intervention for suicidal adolescents and enhance the adolescent’s confidence in a their families (11). During 60-90 minutes parent’s availability. The therapist provides FBCI program, clinician helped the suicidal a supportive and reflective listener who adolescent and their parents develop a joint encourages the adolescent to explore and crisis narrative of the problem and taught clarify distressing thoughts and feelings them cognitive behavioral skill building, in FE-NST. FE-NST was included five therapeutic readiness, psycho-education sessions for parents with contents in joint about depression, and safety planning. parent–teen safety planning and parent The outcome was assessed at five time psychoeducation about their adolescent’s points over the course of the study: before depressive and suicidal symptoms. The randomization, after evaluation/intervention measurements of suicidal and depressive in the ED, and via telephone at 3 days, 1 symptoms were collected monthly through week, and 1-month after the ED visit. Week 16 (posttreatment). 3.4. Study quality It is interesting to get more information The risk of bias within studies is displayed about the comparison of two interventions in Table 2. All studies applied an appropriate between PA-CBT and AO-CBT. Moreover, study method to address a focused both parents and their children had diagnosis research question. The included studies of MDE. Two programs were contained 12 were critically appraised for methodological sessions over 12 weeks. Adolescence who quality and risk of bias based on “Cochrane participated in AO-CBT and PA-CBT, will Risk of Bias Tool” (29).The majority of received safety plans, core skills including these studies used random sequence problem solving, cognitive restructuring, generation and used adequate allocation affect regulation, behavioral activation, concealment strategies (6, 8, 11, 26). Of relapse prevention. Parents in the AO- the six studies that four assessed outcomes CBT participated in end of most sessions, by interview face to face, one study used especially in safety discussion sessions. self-report and the other one applied both Similarity, the adolescent sessions in PA- self-report and interview via telephone. CBT were essentially the same as those Almost studies reported assessor blinding in AO-CBT. Parent sessions comprised (6, 8, 11, 26, 27). All six studies reported the same skills as their children’, using conducting intention-to-treat (ITT) analysis. the same format for better communication Four studies reported less than 15% drop between them about skills. In the PA-CBT out and were classed as low risk (27). Two condition, all individual sessions concluded interventions included SAFETY program with a conjoint meeting between parent and (26) and FBCI (11) which were assessed teen. The check-in included an exchange of as low risk of bias for all domains. positive comments between the parent and teen to enhance positive communication 3.5. Effectiveness of the intervention and a review of the skills learned (28). Then For the primary outcome of reduce they all completed all research evaluations suicide ideation, suicide thought, suicide at four time points: baseline, mid-treatment behavior in adolescences, all six studies Journal of Nursing Science - Vol. 04 - No. 01 103
7. RESEARCH ARTICLE reported reduction in suicidality of the point without an ED visit for suicidality was young. In RAP-P intervention, the result significantly lower for E-TAU compared showed greater reductions in adolescents’ to SAFETY youths and there were no suicidal behavior and psychiatric disability, statistically significant for hospitalizations compared to RC alone (6). There was between intervention and control group evidence of a significant reduction in (26). Three adolescents in PA-CBT group suicide ideation, suicide attempt and were psychiatrically hospitalized during hopelessness between baseline and intervention phase one for emotional distress three-month follow-up, even though one after revealing sexual abuse occurred in the suicide attempt (3.1%) at the 3-month and family, one for suicidal ideation and cutting, another by 6-month (6.2%) cutting with and one for being unable to contract for intention of relieving distress and no intent safety were addressed in study of Spirito to die (27). Adolescences in both conditions et al., (28). In FBCI study, results of a demonstrated significant improvement in randomized controlled trial of FBCI versus suicidal ideation from baseline to end of TAU show significant reductions in inpatient treatment, remained low throughout follow- hospitalization rates in the FBCI group up (28). Compared to E-TAU, the SAFETY compared with those demonstrated in their treatment lowered the probability of a TAU counterparts (11). suicide attempt and an estimated suicide Secondary outcome in enhancing family attempt risk of 0.33 in the E-TAU group at relationship refer to family functioning the 3-month follow-up point and between 3-6 were found in two studies (6, 8). Family months, one suicide attempt in SAFETY but focused interventions had showed positive seven suicide attempts in E-TAU (26). On improvement in family functioning and thus average, adolescents reported a significant reduce adolescent depressive symptoms decrease in suicidal ideation from the in both studies. However, this positive beginning to end of treatment. On average, result had no significant relationship with this rate of change corresponded to a total reduction in suicidality of teenagers. decline of 29.26 points on the Adolescents’ Regarding to the measurement tools suicidal ideation scale (SIQ-JR) between to assess suicide risk of adolescence, baseline and posttreatment. Adolescents researchers applied six different from traditionally underserved (non-White questionnaires in six studies. Australian or lower income) families showed greater researchers (6) used Adolescent Suicide reductions in suicidal ideation in both Questionnaire-Revised (ASQ-R) which was treatments (8). Finally, no completed suicide developed from the original ASQ widely was reported in all six studies during the applied with Australian secondary school study period in either condition. students. ASQ-R included nine items to In relation to suicide attempt or self- document suicide ideation, plans, and harm, reduction of admission rate had been threats, deliberate self-harm, and suicide reported in four studies during and after the attempts. Four items measured frequency intervention programs. Four youths (12.5% (0=never to 3=all of the time), and 5 items of the sample) were seen in the ED and measured recency (0=never, 1=in the last hospitalized during the 3-month follow-up 12 months, to 3=in the last month). These period due to deliberate self-harm (27). items were summed to form a total ASQ-R Continue their study of SAFETY program, score for each adolescent at each time the authors reported the probability of point (Cronbach alpha=0.74). Four studies survival to the 3-month posttreatment in United States applied four differences 104 Journal of Nursing Science - Vol. 04 - No. 01
8. RESEARCH ARTICLE measurements to assess adolescences total scores (α values ranging from 0.89 with suicidality. In RCTs trial conducted by to 0.95) as well as concurrent and known- Asarnow et al., in 2015, Suicidal behaviors groups validity. Finally, Ireland researchers (Columbia Suicide History Form) was applied Beck Suicide Scale (BSS) for both applied for coding timing, method, and adolescents and parents in their study. lethality of suicidal/self-harm behavior. Internal consistency for this sample on Research team have previously developed the BSS were excellent (a=0.90 for both quality assurance procedures indicated adolescent measures; a=0.93 and 0.95 for strong quality (Mean =1.2, SD=0.54, 3-point parents, respectively). scale 1=good to 3=poor). In addition, to 4. DISCUSSION assess suicidal behavior and ideation and passive suicidal ideation authors used self- This review examined six studies of report on the 17-item Harkavy Asnis Suicide family-based intervention designed to Survey (HASS) (27). However, in the next reduce suicide risks among adolescences. RCTs in 2017, authors applied Columbia All of studies were conducted in high Suicide Severity Rating Scale (C-SSRS) income countries and participants with to assess suicide attempt and self-harm suicide ideations or attempts were which contains probes and scales for rating referred from ED and psychiatric hospitals. severity of suicidal behavior plus a parallel Intervention settings, content, therapists scale assessing nonsuicidal self-injury were varied across programs. The average (NSSI) and the Suicide History Interview of participants from 11 to 18 years old (26). Suicidal Ideation Questionnaire- with female dominant, suggesting that Junior (SIQ-JR) was employed to assess the finding from the interventions may be adolescents’ suicidal ideation by Zisk et al., most applicable to young people under 18 (8). This is a 15-item self-report measure years old and their caregivers. Overall, all with statements such as “I thought about the programs identified in review reported killing myself” and “I thought about how I significant effects on suicidal ideation, would kill myself.” Each item is rated on a suicide attempts or deliberate self-harm, 7-point scale that assesses the frequency especially no completed suicide during the of these suicidal thoughts (1=absence of intervention and follow-up period. Small the thought,7=the thought has occurred to large effect sizes were reported by the almost every day for the past month). effective programs with short- and long- Authors reported in their current sample, term effectiveness evidence. This result the SIQ-JR demonstrated good internal could be explained due to the drop-out consistency (Cronbach alpha = .84). In rate more than 15% in more than a half study of Wharff et al., they used Reasons of studies. This highlights the importance for Living Inventory for Adolescents (RFL-A) of sufficiently powering studies to detect to measure the presence of adaptive expected intervention effects. qualities and associated protective factors Family had strong evidence of ability to of suicidal adolescent populations (11). The provide a safe and containing environment RFL-A is a 32-item self-reports contains 5 for their child during hospitalization and subscales: family alliance, suicide-related in the community (11, 13). Intervention concerns, peer acceptance and support, included both individual and conjoint self-acceptance, and future optimism. The meeting reported effects for both suicide RFL-A had reported high levels of internal ideation and attempts which maintained consistency with respect to subscales and during follow-up process. However, very Journal of Nursing Science - Vol. 04 - No. 01 105
9. RESEARCH ARTICLE few studies were identified family function that some studies were not captured by our or caregivers’ competence of suicide search strategy and therefore not identified management as the primary outcome; in our review. Another limitation of this this may be an area for further program review is that the measurement of suicidal development and to examine the potential ideation, suicide attempts and deliberate association and the mechanisms contribute self-harm differed widely among studies to the effects. with self-report measurement and face-to- This review suggested strong evidence face interview. As a result, the quality of the for implementation of family-based suicide data collection may vary between studies. prevention program in ED, psychiatric There is a suggestion for further practical hospital, pediatric hospital and home of training program to enhance general participants. All of these settings were nurses’ abilities of suicide risk identification, found to be effective for adolescences with assessment and manage this population. suicide ideation and attempts. The most Finally, our searching criteria did not include effectiveness and applicability program non-English language so that there might in this review was FBCI which was 60- be other effective programs not appear in 90 minutes single-session-ED-based our result. for adolescents and their families in ED 5. CONCLUSION setting (11). This result suggested a widely application for every teenager who admitted Even though there are not many family- to the ED due to suicide behaviors. Family- based suicide prevention programs for based intervention especially in crisis offer a adolescences with suicidality available promising alternative to traditional inpatient for the implementation in hospital setting care while enhance family empowerment or at participants’ home, there is powerful and adhering to objective of the growing evidence on their efficacy. The intervention community-based movement (11). In implementation process should take into additional, to reduce barriers to treatment account intervention specifics, development attendance and to strengthen understanding process, culture context where intervention of the home and community environment, is going to develop and characteristics of SAFETY program was strongly suggested environment where the intervention should for further implementation at teenagers’ be implemented. In addition, the intervention home. These results show a good strategy must be handed by healthcare professional which target suicide prevention and early that has appropriate knowledge and skill intervention program for young people and for prevention, management and promotion their family members during crisis in ED of suicidality and mental health disorders. or psychiatric setting and at participants’ There is a need for investing in nursing home. With multi approaches for selective education to ensure the best care and and indicated interventions in this review, support strategy for reducing suicide rate of there is a need to further explore universal adolescences. program in this population. 6. IMPLICATION There are some limitations to the current review that should be addressed. This This review provided a robust evidence review excluded studies did not include for implication of family-based suicide suicide outcome measures but may have prevention program for every teenager who had positive effects as seeking behavior, admitted to the ED, psychiatric hospital, literacy and attitudes. It is also possible pediatric hospital due to suicide behaviors. 106 Journal of Nursing Science - Vol. 04 - No. 01
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12. RESEARCH ARTICLE 27. Asarnow JR, Berk M, Hughes JL, findings. Journal of child and adolescent Anderson NL. The SAFETY Program: psychopharmacology. 2015;25(2):131. A Treatment-Development Trial of a 29. Higgins JP, Altman DG, Gứtzsche Cognitive-Behavioral Family Treatment for PC, Jỹni P, Moher D, Oxman AD, et al. The Adolescent Suicide Attempters. Journal of Cochrane Collaboration’s tool for assessing Clinical Child & Adolescent Psychology. risk of bias in randomised trials. BMJ. 2015;44(1):194-203. 2011;343:d5928. 28. Spirito A, Wolff JC, Seaboyer LM, 30. Boswell C, Cannon SB, Miller J. Hunt J, Esposito-Smythers C, Nugent N, Students’ perceptions of holistic nursing et al. Concurrent treatment for adolescent care. Nursing education perspectives. and parent depressed mood and suicidality: 2013;34(5):329-33. feasibility, acceptability, and preliminary Figure 1: Prisma flow chart Records identified through Additional records identified database searching through other sources Embase = 317 (n =15) MEDLINE = 57 Cochrane = 62 Identification Records after duplicates removed (n = 422) Records excluded (n = 262) 1. Not included caregiver 2. Not an RCT Screening Records screened 3. Irrelevant studies (n = 422) 4. Systematic reviews or meta- analysis 5. Cost effectiveness Full-text articles excluded (n = Full-text articles 154) assessed for eligibility 1. No data on suicide outcomes (n = 160) (n=66) 2. Research protocol (n=5) Eligibility 3. Not adolescent or young adult Studies included in review (n = 06) Included Journal of Nursing Science - Vol. 04 - No. 01 109
13. RESEARCH ARTICLE Table 2: Characteristic of included studies N Author/ Design/ Criteria Intervention Measurements Outcomes Country Participant 1 Jane Pineda, RCT; Inclusion: *RAP-P: 4 + Adolescence: *PO: Mark R. pre-treatment, Adolescents sessions, 2h/ Adolescent adolescent Dadds, 2013, 3m, 6m 12-17 ys; session per Suicide suicide-self Australia depression, 1-2w up to 2.5 Questionnaire- harm risk and N=48; PTSD, anxiety months interactive Revised psychiatric I=24 SI, SA or DSH psychoeducation (ASQ-R); impairment and C=24 within the last program for Strengths and the 2 months; one parents Difficulties *SO: family parent (biological Questionnaire adjustment or adoptive) was *Routine (SDQ) primary carer; Care: crisis + Parents: SDQ an average or management, *Clinician: above-average safety planning, Health of intellectual level; individual the Nation basic English psychoeducation, Outcomes Scale language abilities nonspecific for Children and counseling, Adolescents Exclusion: supportive (HoNOSCA) psychosis; therapy, cognitive- developmental behavior therapy, Family disorders pharmacological Assessment treatment Device (FAD) RAP-P + RC Delivery together parent and adolescence RC No parents’ involvement 2 Joan RCT pilot; Inclusion: youths Length: 20 + Baseline, *PO: reduce Rosenbaum baseline, 3m, 11-18ys; SA sessions over 12 3-months: suicidal behavior Asarnow et 6m, follow-up in past 3m; weeks (incl: 1ì Diagnostic *SO: reduce al., 2015; stable living family session Interview youth & parent USA N=35; situation; parents then Schedule for depression, no control participate. individual (16 x Children & hopelessness, group youth-only & Adolescents social Exclusion: parent-only), then (NIMH DISC adjustment no contact up to 16ìfamily IV); suicidal information session) behaviors available for (Columbia follow-up; * SAFETY Suicide History psychosis; Program Form); Harkavy substance 1) Asnis Suicide abuse/ psychoeducation Survey (HASS) dependence; 2) identify youth Youth & parent: not English- and family Center for speaking; strengths; Epidemiological no family to 3) emotional Studies- participate thermometer; 4) Depression “safety plan” for Scale (CES-D), reducing Beck 110 Journal of Nursing Science - Vol. 04 - No. 01
14. RESEARCH ARTICLE “emotional Hopelessness temperature” and Scale (BHS); SA-risk; 5) “Safety Social Plan Card” Adjustment Developed by Scale-Self Henggeler (2002) Report for Youth (SAS- SAFETY Program SR), Treatment Delivery individual Satisfaction then together Scale,The parent and Service adolescence Assessment for Children and Adolescents (SACA) Youth: Drug Use Screening Inventory (DUSI) Parent: Child Behavior Checklist (CBCL) + 6-months follow-up: parent telephone- interviews DISC, SACA. 3 Joan RCT; Inclusion: 11- *12 weeks Columbia PO: incident Rosenbaum baseline, 3m, 18ys; recent SA SAFETY program, Suicide Severity suicide attempts Asarnow et 6m, 12m; or NSSI (past 3m; skill-building Rating Scale al., 2017; 3m); repetitive based on CBFA; (C-SSRS); Mood USA N = 42 SH (≥3 lifetime); 3 final weeks & psychosis I=20; stable family brought youths, disorders (DISC C=22 situation, parents, therapists IV); The Service one parent together to Assessment for participated practice “safety” Children and skills and Adolescents Exclusion: behaviors skill (SACA); symptoms (consolidation, Center for interfering relapse Epidemiological (psychosis, prevention, Studies– substance use); linkage to needed Depression inability to speak services) 2 Scale (CES-D); English therapists for 1 The Drug Use family, one for Screening youth, other for Inventory parents; (DUSI); Youth SAFETY Program Self-Report Delivery (YSR) and 9 sessions parent report individual parent (Child Behavior and teen, 3 Checklist session together (CBCL) parent and adolescence *E-TAU: treatment as usual enhanced by an in-clinic parent Journal of Nursing Science - Vol. 04 - No. 01 111
15. RESEARCH ARTICLE education session, follow by ≥ 3 telephone calls supporting motivation; actions to obtain follow-up treatment. 4 Abigail Zisk RCT, *Inclusion: 12- 16 weeks, five + Baseline: PO: suicidal et al., 2019, monthly 18ys, severe tasks cooperative and depressive USA assessments SI ≥ 31 SIQ- ABFT: communication symptoms through JR; moderate conversations (GPACS), week 16 depression ≥ 20 about perceived parent– (posttreatment) BDI-II attachment adolescent N=129 ruptures, dyads were ABFT=66; *Exclusion: risk improvement video-recorded FE-NST=63 of harm to self/ in the parent 10-min conflict others, psychotic – adolescent discussion, Self- symptoms, relationship. Report of Family severe Functioning impairment FE-NST: safety Conflict scale in cognitive planning, (SRFF), functioning; understanding + Monthly antidepressant adolescent symptom medication depression, assessments: within 3 weeks assessing suicide BDI-II, Suicidal of the initial risk, enhancing Ideation assessment; not advocacy Questionnaire- willing caregiver and resource Junior SIQ-JR to participate; not development, speak English and increasing problem-solving ABFT Delivery 3 task together parents and teen, 2 tasks separate FE-NST Delivery only parents 4 tasks, together parent and teen 1 task 5 Elizabeth A. RCT; *Inclusion: FBCI: one Reasons for *PO: suicidality, Wharff et al., pre, post, 13-18ys, SA session, 60- Living Inventory family 2019, USA 3days, 1week, in 72 hours, a 90mins, research for Adolescents empowerment 1m parent noted clinician helped (RFL-A), Family N=142 direct behaviors the suicidal Empowerment *SE: parent indicating adolescent Scale (FES) satisfaction suicidality, and parents Client presence of develop a joint Satisfaction a consenting crisis narrative Questionnaire parent/ legal of the problem (CSQ-8) guardian with and taught Parents/ whom the them cognitive guardians adolescent behavioral answered two resided, parent/ skill building, questions at guardian agreed therapeutic each follow-up to participate. readiness, time point.: 112 Journal of Nursing Science - Vol. 04 - No. 01
16. RESEARCH ARTICLE Exclusion: lack psycho-education “Since your fluency English, about depression, initial visit to the not medically and safety ED, has your stable, cognitive planning child required limitations, another crisis active psychosis, evaluation?” required physical FBCI and “Since or medication Delivery together your initial visit restraint in the parent and to the ED, has ED adolescence your child been psychiatrically TAU: standard hospitalized psychiatric again?” evaluation and clinical/discharge recommendations 6 Anthony RCT; Inclusion: 12 sessions over + Adolescence: *PO: suicidality, Spirito et al., baseline, adolescent and 12 weeks Beck Suicide depression 2015, Island mid-treatment parent dyads Scale (6w), end of lived together, *AO-CBT: safety (BSS), BDI-II, treatment spoke English. plans, core skills Hopelessness (12w), 48w Adolescence: including problem Scale for follow-up 11–17 ys; current solving, cognitive Children (HSC), MDE; Clinical restructuring, The McLean N = 24 Depression affect regulation, Screening PA-CBT = 16 Severity Rating behavioral Instrument AO-CBT = 08 Scale (CDRS) activation. for Borderline >=65; current or * PA-CBT: same Personality past suicidality Disorder (MSI- as in AO-CBT. (BDI-II) or BPD), The Parent sessions (K-SADS-P) Childhood Parent: either comprised the Trauma current or past same skills Questionnaire MDE; BDI >= 15 as adolescent (CTQ) with a current sessions. + Parent: BSS, MDE, >= 10 with Medication BDI-II, Beck a past MDE. management: Hopelessness met with the Scale (BHS), Exclusion: study psychiatrist MSI-BPD, bipolar disorder, for medication + Middle + End substance management. treatment of use disorder, PA-CBT : Client developmental/ PA-CBT Satisfaction cognitive delays, Intervention Questionnaire psychosis for parent and (CSQ), The adolescence Working Alliance separate but each Inventory (WAI) session had one + Clinician rate: conjoint meeting. K-SADS & The Structured AO-CBT: Clinical Interview Delivery only for for DSM-IV – Adolescents. Patient Version Parents (SCID-I/P); CDRS participated only in the end of-session and involved in safety concerns sessions Journal of Nursing Science - Vol. 04 - No. 01 113
17. RESEARCH ARTICLE Notes: ED = Emergency Department; ITT = intention-to-treat; IQR = Interquartile Range; MA = meta-analysis; MH = mental health; NR = not reported; TAU =treatment as usual; SA = suicide attempt; SD = standard deviation; SH = self-harm; SI = suicidal ideation; SRB = suicide-related behavior; PTSD=posttraumatic stress disorder; NSSI = non-suicidal self- injury; major depressive episode = MDE; PO: primary outcome; SO: secondary outcome; I = intervention; C = control Table 3. Risk of bias for included studies Less Blinding of Random Blinding of than Ascertainment participants ITT analysis Study sequence outcome 15% of DSH and undertaken generation assessment drop-out repetition personnel rate (6) Yes No Yes No Yes Interview (27) NR No Yes Yes Yes Interview (28) NR No NR Unclear Yes Interview (26) Yes No Yes Yes Yes Self-report Self-report + (11) Yes Yes Yes Yes Yes interview via phone (8) Yes No Yes No Yes Interview NR: not report, DSH: deliberate self-harm, ITT = intention-to-treat 114 Journal of Nursing Science - Vol. 04 - No. 01