Children and Youth Services Review 33 (2011) 2112–2118

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Children and Youth Services Review

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A systematic review of psychosocial interventions for suicidal adolescents☆

Jacqueline Corcoran ⁎, Patrick Dattalo, Meghan Crowley, Emily Brown, Lauren GrindleVirginia Commonwealth University, United States

☆ With grateful acknowledgements to Courtney MorRachel Ralston, Dan Ream, Jason Spatz.⁎ Corresponding author.

E-mail address: jcorcora@vcu.edu (J. Corcoran).

0190-7409/$ – see front matter © 2011 Elsevier Ltd. Aldoi:10.1016/j.childyouth.2011.06.017

a b s t r a c t

a r t i c l e i n f o

Article history:Received 29 March 2011Received in revised form 8 June 2011Accepted 10 June 2011Available online 26 June 2011

Keywords:Systematic reviewMeta-analysisAdolescentSuicideInterventionSuicidal behavior

Suicide is a leading cause of death for young people and rates of serious suicidal thoughts are even higher. Dueto these high rates and potential harm to youth, effective interventions are necessary. The purpose of thissystematic reviewwas to determine the impact of interventions designed for suicidal adolescents. Both quasi-experimental and experimental designs in the published and unpublished literature were included, and atotal of 17 studies were located. According tometa-analysis, intervention group participants were slightly lesslikely to have suicidal and self-harm events than control group participants. However, when studies assessedoutcome at a later period than immediately after intervention, experimental group participants were slightlymore likely to have suicidal and self-harm events than control group participants. For studies that measuredsuicidal ideation at posttest, intervention group participants were slightly less likely to report suicidal ideationthan control group participants, both at posttest and at follow-up. These contradictory findings are exploredand discussed.

rison, Stefanie Quinones-Bass,

l rights reserved.

© 2011 Elsevier Ltd. All rights reserved.

1. Introduction

According to the most recent figures from the Centers for DiseaseControl (2007), suicide is the third leading cause of death for youth ages15–24, accounting for 12.9% of all deaths annually. In the 2007 NationalYouth Risk Behavior Survey, 14.5% of U.S. youths had seriouslyconsidered suicide and 6% actually made an attempt. Given the extentof suicidality in youth and its potentially devastating consequences,mental health professionalsworkingwith this population need to knowthe effectiveness of interventions.

1.1. Literature review

We begin the literature review with those reviews that havecentered on self-harm as such events can lead to suicide. A CochraneCollaboration systematic review was conducted on interventions forpeople who had committed an act of self-harm (Hawton, Townsend,Arensman,Gunnell et al., 2000).Only randomized, controlled trialswereincluded, and samples comprised both adults andadolescents. Results ofthe 23 primary studies were not analyzed separately for adolescents,and only two studies actually involved teen samples (13–18 years ofage). The review concluded that there was “insufficient evidence” todemonstrate the effectiveness of interventions for those who hadcommitted acts of deliberate self-harm.

Another, more recent systematic review, focused solely onmortality from suicide when psychosocial interventions were imple-mented with people who had committed self-harm (Crawford,Thomas, Khan, & Kulinskaya, 2007). Only randomized, controlledtrials were included. There was no mention of whether samples wereto be limited by age, so presumably studies with adolescents could beincluded. With these inclusion criteria, 18 trials were meta-analyzed.Results indicated that psychosocial interventions did not reducesuicide rates over control group conditions, which typically offeredsome care. Results were not provided separately for adolescents. Oneproblem with “completed suicide” as an outcome is that it isinfrequent enough “to limit is usefulness as an outcome measure. . .in spite of its obvious importance” (Tarrier et al., 2008).

Another systematic review centered only on cognitive-behavioralinterventions to reduce suicidal behavior (Tarrier, Taylor, & Gooding,2008). The researchers argued for including the spectrum of suicidalbehavior to include “completed suicides, suicide attempts, suicideintent and/or plans, and suicide ideation” as a possible continuummay lie “from ideation, through intent and planning, to action”(Tarrier et al., 2008, p, 79). Only published experimental and quasi-experimental studies from 1980 were included. Seven of the 28studies involved adolescent samples. Although the effect size for thestudies involving adult samples was statistically significant, the effectsize for the adolescent studies were not. Therefore, it appears thatcognitive-behavioral interventions for suicidal youth were noteffective; however, the sample size of seven studies was small.

More recently, a literature review was published on interventionsfor suicidal youth (Daniel & Goldston, 2009). Twelve publishedstudies were included (five were quasi-experimental designs andseven were randomized controlled trials). Meta-analysis was not

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performed; each study was only discussed in terms of statisticalsignificance. The conclusion of Daniel & Goldston (2009) was asfollows:

…it appears that interventions for suicidal youth have been ingeneral more successful at affecting aspects of service utilizationand delivery (e.g., compliance with medical recommendations,aftercare utilization, reduced hospitalization, decreased time tooutpatient appointments) than in reducing rates of suicideattempts per se (p. 259).

The authors complained about the diversity of outcomes in termsof suicide attempts, suicidal ideation, and severity of suicidal ideationin being able to determine the effectiveness of studies.

A final study of relevance here is a meta-analysis on psychotherapyfor child and adolescent depression (Weisz, McCarty, & Valeri, 2006).Dissertations were included, alongwith the published research.Weiszet al. (2006) located 35 studies, and found a small overall effect sizefor improvement of depression at posttest, but a negligible impact onsuicidality.

In order to overcome the limitations of previous reviews (notanalyzing adolescent samples separately, not considering the range ofinterventions beyond CBT, not considering outcomes of both self-harm and suicidal ideation, limiting the literature to only publishedstudies, and failing to perform quantitative synthesis of outcomes),the current systematic review was undertaken. The purpose is todetermine the effectiveness of psychosocial interventions for youthwho have been identified as suicidal.

2. Methods sections

2.1. Search strategy

The following inclusion criteria were used for this review:

• Types of studies: Published and unpublished experimental andquasi-experimental designs with no restriction on start date toSpring 2010.

• Types of participants: Adolescents aged 10–18 presenting withsuicidal thoughts or suicidal behavior.

• Types of interventions: Psychosocial interventions only withparticipants who were identified as suicidal; while participants ofstudies could be taking medication, the sole purpose of the studywas not to evaluate the effects of medication. Prevention studies(preventing suicide in those not previously identified as suicidal)were excluded.

• Types of outcome measures: self-report, standardized measures ofsucidiality; self-harm and suicidal events, including attempts(collected by teen report or administrative data)

In applying these inclusion criteria, first, the reference lists of thepublished reviews were hand searched for relevant studies. Addi-tionally, two masters students enrolled in an advanced researchcourse independently searched the following bibliographic databases(with the number of initial hits indicated in parentheses): PubMed/MedLine (312); PsycInfo (123); CINAHL (309); Dissertation Abstracts(190); and Academic Search Complete (27). Appropriate search termswere generated for each data base by a research librarian. Based ontitle and abstract review, 48 studies were examined in full text, andthe remaining screened out. The reasons for exclusion at this pointincluded: 1) lack of control groups; 2) studies involving primary orsecondary prevention rather than involving those teens alreadyidentified as suicidal; 3) the outcome was not suicidality or self-harm events; 3) the sample involved adults or did not separate outanalysis for adolescents when adults and adolescents were studyparticipants.

2.2. Data extraction

A data extraction instrument was developed by the first authorand adapted from Littel, Corcoran, and Pillai (2008). Coding sheets foreach study included information on sample, intervention, andmethodological characteristics, and the statistical information neces-sary to calculate effect sizes. Studies were coded independently bytwo trained graduate social work students enrolled in an advancedresearch course, as well as the principal investigator, with discrep-ancies resolved by discussion.

2.3. Data analysis

All statistical analyses were performed with NCSS 2007 statisticaland power analysis software, which is a multi-purpose statisticalpackage with procedures for conducting meta-analyses and supportinggraphs and diagrams (NCSS, 2007). Studies included in this meta-analysismeasured intervention outcomes in twoways. First, analyses ofthe number of suicidal and self-harm events include (1) study-specificodds ratios (ORs) for no event (success) versus event (failure) withcorresponding95% confidence intervals (CIs), (2) Corcoran'sQ statistics,and (3) Forest plots. Second, analyses of the level of suicidal ideationsinclude (1) study-specific Cohen's ds with corresponding 95% confi-dence intervals (CIs), (2) Corcoran's Q statistics, and (3) Forest plots.

An OR is defined as the ratio of the odds of an event (e.g., suicidaland self harm) among an intervention group participants comparedwith the odds of that same event among a control group participants.The OR is a way of comparing whether the probability of a certainevent is the same for two groups. Accordingly, an OR of one impliesthat the event is equally likely in both groups; an odds ratio greaterthan one implies that the event is more likely in one group (i.e., theintervention group). An OR less than one implies that the event is lesslikely in one group (i.e., the intervention group). Outcomes wereassessed at posttest (immediately following the end of intervention)and at similarly grouped follow-up periods.

Cohen's d is a measure of effect size based on the standardizeddifferences between two means. Cohen's d is defined mathematicallyas the difference between the means of two groups (e.g., interventionand control) divided by the pooled standard deviations of these twogroup means. Cohen's thresholds for small, moderate and large effectsizes are 0.20, 0.50 and 0.80 respectively.

Fixed effects and random effects models were calculated. In fixed-effects models, the study effects estimate the population effect withthe only error being from the random sampling of participants withinthe studies. In contrast, random-effects models assume that variabilitybetween ESs emerges from participant-level sampling error and fromrandom differences between studies that are associated withvariations in experimental procedures and settings.

It has been argued that random-effects models more adequatelymirror the heterogeneity in behavioral studies and use non-inflatedalpha levels when the requirement of homogeneity has not been met(Hunter & Schmidt, 2000; Mullen, 1989; Rosenthal, 1984). Heteroge-neity was analyzed by computing Corcoran's Q statistic, which has anapproximate chi-square distributionwith p – 1° of freedom,where p isthe number of categories within each moderator variables (Hedges &Olkin, 1985). Statistical significance was defined as pb0.10 ratherthan the more conventional 0.05 because of the low power of this test(Hedges & Pigott, 2001).

3. Results

A total of 17 studies met our inclusion criteria for this review.Study designs included seven quasi-experimental and 10 experimen-tal designs and involved a range of interventions. Participants tendedto be about 15 years of age. Although a majority of the samples wereCaucasian, some studies had subjects that were primarily of ethnic

Table 1Design, sampling, and program information for included studies.

Author (Year) Study design Sample/demographic information Program description and duration Setting

⁎Amish(1991)

Quasi-experimental N=3067% female; predominantlyCaucasian (Exp— 87%, Control 93%)Mean age 15 years

CBT group therapy5 days

Inpatient hospitalFlorida

⁎Brent et al.(2009)

Quasi-Experimental N=12422.6% maleMean age=15.8 yrs.70% Caucasian, 13% African-American,15% Latino

Cognitive-behavioral therapy6 month.

Academic medical settings5 sites through the U.S.

⁎Cotgrove,Zirinsky,Black, andWeston(1995)

Experimental Started treatment=105 Completedtreatment=105 Completed 1st f-u(1 year)=10584.8% female 15.2% maleMean age=14.9

Token system N/A Seven local child andadolescent department/clinicsNorth London

⁎Deykin,Chung-Chen,Joshi, and McNamarra(1986)

Quasi-Experimental 172 Ss (aged 13–17 year) requiringemergency medical treatment forself-inflicted injuries. 147 age-matchedcontrol Ss were offeredonly standard hospital treatment and services.38% male, 62% female Treatment: 28%; Control:68% Caucasian Treatment: 57%; Control:4% African American Treatment: 15%;Control: 28% Other

Combined community educationand direct service4-day long conferences for adultsand 4-day long conferences for adolescents

Conducted in 2 urbanhospitalsBoston, Massachusetts

⁎Diamond et al. (2010) Experimental N=6674% African-American83% female41% income less than $30,000Mean age=15.1

Attention-Based Family Therapy –

emotion-focused, processing toimprove attachment bonds3 month.

Children's HospitalPhiladelphia, Pennsylvania

⁎Donaldson,Spirito,andEsposito-Smythers(2005)

Experimental Started treatment=39Completed 3- and/or 6-month follow up=3118% male, 82% femaleMean age=15.085% White, 10% Hispanic, 5% African American

Skills-based treatment (SBT) andSupportive relationship-basedtreatment (SRT)6 individual sessions and 1 familysession during first 3 months;3 monthly sessions during next3 months

Pediatric emergencydepartment or inpatient unitof an affiliated childpsychiatric hospitalNortheast United States

⁎Greenfield, Larson,Hechtman,Rousseau, andPlatt (2002)

Quasi-Experimental Started treatment=286 Completedtreatment=notspecified Completed 1st f-u(6 months)=not specified

Rapid-Response Outpatient ModelUnspecified range: Mean durationof treatment=17.69 weeks

Conducted at one of twopediatric emergencydepartmentsMontreal

⁎Harrington et al.(1998)

Experimental Started treatment=162 Completed 1st f-u(2 months)=154 Completed 2nd f-u(6 months)=149 16 years old or younger

Home-based family intervention5 sessions

Hospital and Home BasedManchester, England

⁎Hazell et al.(2009)

Experimental Started treatment=72 Completedtreatment=6891% female, 9% male,Mean age=14.5 yrs

Group therapy6 – 12 months

Child and adolescent mentalhealth ServiceNewcastle, Brisbane North,or Logan Australian

⁎Huey et al.(2004)

Experimental Started treatment=156 Completedtreatment=unknown65% male; 35% female, Mean age=12.9 yrs,33% Caucasian, 65% African American, 1% Otherpredominantly low socioeconomic status

Multisystemic Therapy (MST)1 year

Hospital and Home BasedMedical University ofSouth Carolina

⁎Katz, Cox,Gunasekara,and Miller (2004)

Quasi-Experimental Started treatment=62 Completed 1st f-u=5384% male, 16% female, Mean age=15.4 yrs,72.6% Caucasian, 19.4% First Nations, 1.6% Other

Dialectical Behavior Therapy (DBT)2 weeksIndividual & Group

Psychiatric inpatient unitUniversity of ManitobaSchool of Medicine

⁎King et al. (2009) Experimental Started treatment=448Completed treatment=34271% femaleMean age=15.5984% Caucasian, 6% African American, 2%Hispanic, 8% Other

Youth Nominated Support Team (YST-II)3 months

University or private hospitalMichigan

⁎King et al. (2006) Experimental Started treatment=289 Completedtreatment=23668.3% female, 31.8% male,Mean age=15.3, 82.4%Caucasian, 10.2% AfricanAmerican 7.4% Other

Youth Nominated Support Team (YST-1)6 months

Psychiatric inpatient unitMidwestern United States

⁎Rathus & Miller, 2002 Quasi-Experimental Referred to study=111 Completedtreatment=62%of Treatment group (DBT); 40%of Control group (TAU); 57DBT: 93% female; Control:73% female Mean age:DBT=16.1; Control=15.0 67.6% Hispanic17.1% African American 8.1%Caucasian 7.2% Other

Dialectical Behavior Therapy (DBT)12 weeks

Outpatient admissionsMontefiore MedicalCenter/Albert EinsteinCollege of MedicineNew York

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Table 1 (continued)

Author (Year) Study design Sample/demographic information Program description and duration Setting

⁎Rotheram-Borus et al.(1996, 2000)

Quasi-Experimental Started treatment=140 Completed4th f-u (18 months)=129100% femaleMean age=14.988% Hispanic, 12% other

Specialized Emergency Room (ER)Care; Family Therapy18 months

Hospital outpatient unitColumbia PresbyterianMedical Center, New York

⁎Tang, Jou, Ko, Huang,and Yen (2009)

Experimental Started treatment=73Completed treatment=7365.8% female 34.2% male Mean age=15.25

⁎Wood et al. (2001) Experimental Started treatment=63 Completed 4 ormore sessions=42 Completed 1st f-u(7 months)=62 78% female 22%male Mean age=14.2

Group Therapy7 months

Mental Health ServiceManchester, England

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minorities. Studies offered a range of types of interventions. Six can becategorized as falling under the rubric of cognitive-behavioralinterventions, and four others could be generally categorized as“family therapy”; other interventions do not necessarily grouptogether. Studies were examined to determine whether they metthe following eight methodological qualities: (1) random generationof allocation, (2) allocation concealment, (3) avoidance of perfor-mance bias,(4) attrition bias, (5) detection bias, (6) intention-to-treat,(7) standardized observation periods, and (8) validated outcomemeasurement (see Table 3). Six of the 18 studies included in thisanalysis did not meet (or it was unclear if they met) the eightindicators of methodological quality used in this analysis. See Table 1or more information on study features and intervention characteris-tics. Findings are reported separately for the two major outcomes:1) suicidal and self-harm events; and 2) suicidality (the subjectivereport of feeling suicidal). As well as posttest outcomes, we were ableto calculate follow-up periods that were reported in some studies atthe six-to-seven month period and at a 12-to-18 month period.

3.1. Suicidal and self-harm events

Fig. 1 is a Forest plot of individual study ORs and total (combined)study ORs for post-tests, and for follow-ups at six to sevenmonths and12 to 18 months. These are described according to the variousassessment periods reported in studies.

3.1.1. PosttestFor the six studies that reported outcome measures at posttest,

intervention group versus control group combined or total oddsratios are positive and small. That is, at posttest intervention groupparticipants are slightly more likely to not have a suicidal and self-

Table 2ORs for suicide and self-harm events.

Study Intervention Controls OR 95% CI

# with event/total #

PosttestRathus 1/29 7/82 0.383 0.045 to 3.252Brent 1/14 1/15 1.077 0.0609 to 19.047Greenfield 23/158 14/128 1.387 0.682 to 2.821King 26/151 16/138 1.586 0.811 to 3.102Huey 10/74 7/82 1.674 0.603 to 4.651Deykin 172/175 147/154 2.730 0.694 to 10.748Total (fixed effects) 233/601 192/599 1.492 1.001 to 2.224Total (random effects) 233/601 192/599 1.514 1.008 to 2.2746–7 Month follow-upAmis 4/12 10/12 0.100 0.0144 to 0.693Wood 2/32 10/31 0.140 0.0278 to 0.706Diamond 4/35 7/31 0.442 0.116 to 1.688Donaldson 4/15 2/16 2.545 0.391 to 16.551Hazell 30/34 23/34 3.587 1.011 to 12.731Total (random effects) 44/128 52/124 0.590 0.142 to 2.444Total (fixed effects) 44/128 52/124 0.678 0.376 to 1.223

harm event (i.e., slightly less likely to have suicidal and self-harmevents than control group participants). See Table 2. The total randomeffects odds ratio was larger than the odds ratio for the fixed effectsmodel (1.514 versus 1.492). The confidence interval around the oddsratio for the fixed effects model was narrower than the confidenceinterval around the odds ratio for the random effects model (1.001 to2.224 versus 1.008 to 2.274). The value of Corcoran's Q was 2.4710,p=0.7809. That is, the test of heterogeneity was not statisticallysignificant, and therefore, more emphasis should be placed on thefixed effects model. Because the Q statistic for all reviewed studiescombined did not indicate heterogeneity, a moderator variableanalysis of odds ratios was not conducted. Greater heterogeneity ofoutcomes across time usually is expected as participants move fartheraway from an intervention. Consequently, moderator analyses werealso not conducted on studies that reported follow-ups at 6 to7 months and at 12 to 18 months.

3.1.2. Follow-upFor the five studies that reported outcomemeasures at six to seven

month follow-up, the total OR was negative and small. See Table 2.That is, in contrast to studies with outcomesmeasured at post-test, forstudies with outcome measures at six to seven months, interventiongroup participants were slightly more likely to have suicidal and self-harm events than control group participants. The total random effectsodds ratio was larger than the odds ratio for the fixed effects model(0.590 versus 0.678). The confidence interval around the odds ratiofor the fixed effects model was narrower than the confidence intervalaround the odds ratio for the random effects model (0.142 to 2.444versus 0.376 to 1.223). The value of Corcoran's Q is 16.3644,p=0.0026. That is, the test of heterogeneity is statistically significant,and therefore, more emphasis should be placed on the random effectsmodel.

For the two studies at the 12–18 month follow-up, the total ORswere negative and small. The value of Corcoran's Q was 0.03783,p=0.8458. That is, the test of heterogeneity is not statisticallysignificant, and therefore, more emphasis should be placed on thefixed effects model. The total random effects odds ratio was largerthan the odds ratio for the random effects model (0.556 versus 0.555).The confidence interval around the odds ratio for the fixed effectsmodel was narrower than the confidence interval around the oddsratio for the random effects model (0.238 to 1.291 versus 0.239 to1.294).

3.1.3. Publication biasResults of a meta-analysis may be biased if the probability of a

study being published is dependent on its results. In other words,studies with strong positive findings may be more likely to bepublished. In an attempt to detect publication bias, symmetry in forestplots was explored. In the absence of a publication bias, forest plotsshould be symmetrical with estimates from larger studies in thecenter, flanked equally on either side by the less precise estimates. The

Fig. 1. Suicide and self-harm events: forest plots of ORs for posttest and follow-up.22 The results of component studies are shown as squares centered on the point estimate of the result of each study. Symbols for individual studies (i.e., squares) are proportionate tosample size. A horizontal line runs through the square to show its 95% CI. The overall estimate from the meta­analysis and its confidence interval are at the bottom, represented as adiamond. The center of the diamond represents the pooled point estimate, and its horizontal line represents the confidence interval. Significance is achieved at the set level if thediamond is clear of the line of no effect.

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forest plots would be skewed (i.e. asymmetrical) in the presence of apublication bias. The forest plot depicted in Fig. 1 suggests symmetry.

3.2. Suicidal ideation

Fig. 2 is a Forest plot of individual study Cohen's ds and total orcombined study ds for posttest and for four to six month follow-upand 12 month follow-up. For studies that reported outcomemeasuresat 4 to 6 or 12 to 18 months ds are also negative and small.

3.2.1. PosttestFor the nine studies were included in the posttest analysis, the

total d's were negative and small. That is, at posttest, interventiongroup participants are slightly less likely to report suicidal ideation.Cohen's ds were calculated for fixed effects and random effectsmodels. The total fixed effects d were smaller than the d for therandom effects model (−0.254 versus −0.274). The confidence

Fig. 2. Forest plots of Cohen's ds (mean differ

interval around the odds ratio for the fixed effects model wasnarrower than the confidence interval around the odds ratio for therandom effects model (−0.406 to −0.103 versus 1–0.497 to−0.0515). For the nine studies summarized in Table 3, the value ofCorcoran's Q was 15.7468, p=0.1056. That is, the test of heteroge-neity was not statistically significant, and therefore, more emphasisshould be placed on the fixed effectsmodel. The forest plot depicted inFig. 2 suggests symmetry, suggesting the absence of publication bias.

3.2.2. Follow-upThree studies were included in the four-to-six month follow-up

period. The total fixed effects dwere smaller than the d for the randomeffects model (−0.320 versus −0.375). The confidence intervalaround the odds ratio for the fixed effects model was narrower thanthe confidence interval around the odds ratio for the random effectsmodel (−0.605 to −0.0354 versus −0.955 to 0.205). The value ofCorcoran's Qwas 7.5126, p=0.0234; that is, the test of heterogeneity

ences) for post-tests and two follow-ups.

Table 3Suicidal ideation: Cohen's ds and CIs at posttest.

Study N Intervention N Control Total d 95% CI

Diamond 35 31 66 −0.917 −1.437 to 0.398Tang 35 38 73 −0.768 −1.253 to 0.283Amish 15 15 30 −0.373 −1.129 to 0.382Rotherman 65 75 140 −0.263 −0.599 to 0.0737Donaldson 15 16 31 −0.141 −0.877 to 0.595Wood 28 29 57 −0.104 −0.635 to 0.427Harrington 79 75 154 −0.0677 −0.386 to 0.251Hazell 35 37 72 −0.0466 −0.517 to 0.424Katz 32 30 62 0.117 −0.391 to 0.626Total (fixedeffects)

339 346 685 −0.254 −0.406 to 0.103

Total (randomeffects)

339 346 685 −0.274 −0.497 to 0.0515

1 Indicate those studies that were used in the meta-analysis.

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was statistically significant, and therefore, more emphasis should beplaced on the random effects model.

Two studies assessed outcome at the 12-month follow-up. Thetotal fixed effects d equaled the d for the random effects model(−0.235). The confidence interval around the odds ratio for the fixedeffects model equaled the confidence interval around the odds ratiofor the random effects model (−0.681 to 0.211). The value ofCorcoran's Qwas 0.0513, p=0.8208. That is, the test of heterogeneitywas not statistically significant.

3.2.3. Methodological qualityA potential bias that can arise from systematic differences in the

methodological quality of the studies being reviewed. Since thesample size was too small to support moderator analysis, weconducted a crude estimate of the influence of methodological factors.In this analysis, studies that met at least seven of eight of theindicators were compared with all other studies in terms of effectsizes at posttest. Four of the six studies that met at least seven of theeight indicators of quality reported outcomes at post-test. Wood,Trainor, Rothwell, Moore, and Harrington (2001), Harrington et al.(1998), and Hazell et al. (2009) reported suicidal ideations, and Kinget al. (2009) reported suicidal and self-harm event.

4. Discussion

In summary, studies included in this meta-analysis measuredintervention outcomes in two ways: (1) presence of suicidal and self-harm events, and (2) level of suicidal ideation. For studies thatmeasured the number of suicidal and self-harm events at posttest,intervention group participants were slightly less likely to havesuicidal and self-harm events than control group participants.However, when studies assessed outcome at a later period thanimmediately after intervention, experimental group participants wereslightlymore likely to have suicidal and self-harm events than controlgroup participants. For studies that measured suicidal ideation atposttest, intervention group participants were slightly less likely toreport suicidal ideation than control group participants, both atposttest and at follow-up. These contradictory findings are not easilyexplained. Seen in its most benign light, it appears that interventionsare only slightly effective in helping suicidal teens feel less suicidal,but may also increase self-harm and suicidal events over the longterm.

Since interventions crossed the gamut and included cognitive-behavioral interventions, family therapy, and myriad other programs,it is difficult to argue that developing additional programs to treatadolescent suicidality is the answer. Further, the Q statistic, whichtests the null hypothesis that there is no heterogeneity of results couldnot be rejected for either the self-harm/suicidal or the suicidalideation outcome effect sizes. This finding suggests that there was

homogeneity in the characteristics of studies in terms of theircontribution to effect size. One major characteristic is the type ofprogram involved. Perhaps, in general, programs could be strength-ened by adding a larger component addressing the prevention ofsuicidal events themselves in the future, although suicidal ideation asan outcome could stand to improve, as well. Programs may also needto provide “booster” sessions so that intervention is offered over timeand not just after an initial period of suicidality or after a suicideattempt.

One caution to add is that the longer-term analyses included veryfew studies. For suicidal and self-harm events, only five studiesassessed this outcome at six-to-seven month follow-up, and only twostudies assessed it at 12–18 month follow-up. For suicidal ideation,three studies assessed outcome at four-to-six month follow-up, andonly two studies assessed it at 12 month follow-up. Therefore, furtherresearch in this area may strive to include follow-up of at least 12 to18 and more ideally extend to four to six months to determinewhether these unfavorable findings would indeed remain.

It appears that the findings of this systematic review areunfortunately in line with other reviews, which have found littlebenefit for suicidal interventions over control conditions that tend tooffer usual care and medication (Crawford, Thomas, Khan, &Kulinskaya, 2007; Daniel & Goldston, 2009; Hawton, Townsend,Arensman, Gunnell et al., 2000; Tarrier et al., 2008). Implications forthis review, while tentative due to the small number of studies, arethat specialized programming for suicidal youth over usual care maynot offer additional benefit for these youth. Although this review didnot undertake a cost-benefit analysis, programs appear to offer littlein the way of additional benefit and may only add expense to existinginterventions.

Several limitations need to be noted. Aside from small study sizeand few studies tracking outcomes over time, studies tended to lackmethodological rigor. Moderator analyses were not performedbecause the Q statistic, which tests the null hypothesis that there isno heterogeneity of results could not be rejected for either the self-harm/suicidal or the suicidal ideation outcome effect sizes. Samplesize also did not support moderator analysis.

Despite these limitations, a synthesis of this literature providesimportant findings. It appears that current suicidal interventionprogram for youth may not add benefit over usual care whenconsidering the outcomes of suicidal ideation and self-harm/suicidalevents.

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