Family-based intervention for suicide prevention in adolescences: A systematic review
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
prevention in adolescences. Design: A
systematic review. Data sources: Search
was performed in MEDLINE, Embase
and Cochrane library. Method: Literature
search was performed during April to May
2020 using inclusion and exclusion criteria.
PRISMAguidelineswerefollowed. Identified
records were reviewed by title, abstract and
by the full text by main researcher then
made a quality assessment of the included
studies. Includedstudieswereextractedand
synthesized. Results: In total, 451 articles
were retrieved via database searching.
Following initial screening, 422 full-text
articles were screened, of which six met
our inclusion criteria. The review therefore
includes findings from six studies which
were assessed as high quality. Five studies
were RCTs and one study was RCTs trial
which delivered in both clinical setting and
participants’ home. All six studies reported
harm of the teenagers and no completed
suicide during the treatment and follow-up
period. Conclusion: Overall all studies
were conducted in high-income countries
with refer from emergency departments
and psychiatric hospitals. We identified that
family-based interventions are powerful
evidence to reduce suicidal ideation and
self-harm for adolescences. Implication:
This study ensured rigorous methodology,
followed PRISMA recommendations and
evaluated quality of identified literature
usingCochraneRiskofBiasToolguidelines.
A critical synthesis was performed to
produce a conceptualization of evidence.
The synthesis represents effective family
interventions for suicide prevention of
adolescence with suicide risk.
Keywords:
prevention,
intervention therapy
adolescence,
suicide
family
family caregiver,
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
(2). Suicide and suicide attempts affect
not only the families and friends of those
who died, but also for people still survive.
Nevertheless, the economic costs, social
costs and spiritual costs that one committed
Cor. author: Pham Thi Thu Huong
Email: phamhuong@hmu.edu.vn
Received: Feb 08, 2021
Revised: Feb 15, 2021
Accepted: Mar 05, 2021
98
Journal of Nursing Science - Vol. 04 - No. 01
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
strategies could strongly improve the
comprehension regarding patients ‘suicide
risk situation (17). It is important to
understand whether family-based therapies
implications in suicide prevention strategy
for young people, specifically whether there
are unintended consequences in term of
management and prevention suicide risk
for teenagers.
There is strong evidence that
family relationship takes an important
consideration in suicide risk. To be
illustrated, family factors such as conflict
and poor communication, loss of caregiver,
parent divorces, and psychopathology
in first-degree relatives are risk factors
for adolescent suicide; and adolescents’
deliberate self-harm are often precipitated
by conflicts related to family environment
(5, 6). Moreover, previous studies showed
that lack of supportive adult relationships
was significant associated with adolescents’
depressive symptoms and suicidal ideation
Background
Suicidal ideations and behaviors which
have defined as suicide attempt or self-
harm with clear or unclear suicidal intent.
Reason to admit hospital by deliberate
self-harm significantly predicts subsequent
suicide in adolescences, especially during
the period immediately following discharge
from psychiatric inpatient treatment
associated with highest risk for suicide (18,
(7, 8).
Several findings highlight the
importance and benefit of relationship-
focused treatments for teenagers who
perceived more negative family interactions
(8, 9).
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
RESEARCH ARTICLE
results, some evidences indicated the
2.3. Search methods
problem in delivery the treatment and
intervention for family caregivers of the
young people at risk of suicide (19, 22).
Thus, there is a need for developing a
unique family-based model approach for
management and follow-up adolescences
with suicide thought and behaviors. To do
that it is important to explore existing family
interventions and their effectiveness.
The search strategy was developed
and conducted following PICO framework
with the question: Which family-based
interventions (I) are effective in reducing
suicide risk (O) of adolescence at risk of
suicide (P)?
The primary outcomes of interest were
thereductioninsuicideriskinadolescences.
The secondary outcomes of interest
were enhancing family relationship.
2. RESEARCH METHOD
2.1. Aims
The complete search strategy for
each database can be found in Table 1.
A systematic search of Medline, Embase
and Cochrane Library was conducted 1st
April to 10th May 2020 with the limiters of
English language studies. Time limiters
were applied from 2013 – 2020. Studies
had to be peer-reviewed and published as
full-text: abstract only papers and opinion,
discussion or review papers were excluded.
This systematic review aimed to
examine the effectiveness of Family-
Based Intervention for suicide prevention in
adolescences.
2.2. Design
This systematic review was planned,
conducted and reported in April to May
2020 according to the Preferred Reporting
Items for Systematic Reviews and Meta-
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*
OR deliberate self-harm OR self-
harm)
1
2
(adolescen* OR teen* OR juvenile*
OR secondary school* OR youth*)
57
317
62
15
(family-basedinterventionORfamily
therapy OR family psychotherapy
OR family intervention OR family
treatment OR carer intervention
OR significant other intervention
OR adult relative intervention OR
close relative intervention OR close
person intervention)
3
Total
451
100
Journal of Nursing Science - Vol. 04 - No. 01
RESEARCH ARTICLE
2.4. Search outcome
3. RESULTS
In total 451 citations were uploaded
into Endnote X7 and after removal of
duplicates, the search yielded 422 citations
for screening. The researcher assessed
titles and abstracts for eligibility using
the exclusion and inclusion criteria. The
Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA)
(23) flow diagram shows the results of the
search and screening processes (Figure 1).
3.1. Search results
In total, 451 articles were retrieved via
database searching during the time limit
from2013-2019.Followinginitialscreening,
422 full-text articles were screened, of
which six met our inclusion criteria. The
review therefore includes findings from six
studies (6, 8, 11, 26-28) (see Figure 1).
3.2. Study characteristics
2.5. Quality appraisal
All of included studies were randomized
controlled trials (RCTs) which conducted
in three countries as United States (four
studies), Australia (one study) and Ireland
(one study). Studies were published
between 2013 – 2019. The sample sizes
of six studies ranged from 35 (27) to 142
(11) adolescences with suicide risks and
their caregivers. Almost studies had both
intervention groups and control groups,
one pilot study (27) did not have control
group. Three studies (50%) were provided
at participants’ houses which were decided
by participants’ preference (6, 26, 27).
The others were implemented at hospital
setting as mental health out-patient clinics,
pediatric emergency department and
emergency departments (ED) (8, 11, 28).
An assessment of study quality was
conducted. For all RCTs, this was assessed
based on the Cochrane Collaboration Risk
of Bias Tool (24). In the majority of trials,
as is often the case, blinding of participants
and therapists was not possible (25). Each
trial was therefore assessed with regard
to random sequence generation, blinding
of participants and personnel, blinding of
outcome assessment, ascertainment of
deliberate self-harm, outcome assessor
blinding, whether analyses were conducted
according to the intention-to-treat (ITT)
principle, and rates of attrition. For the latter
criterion, an attrition rate of 15% or less on
the primary outcome at the longest follow-
up point indicated low risk of bias.
Adolescence and their caregivers were
recruited from ED and psychiatric hospitals.
Each study used different standard of
adolescence age such as 12-17 (6); 11-17
(28); 11-18 (26, 27); 12-18 (8) and 13-18
(11), overall adolescent participants were
from 11 – 18 years old. The majority of
adolescences were female (70% - 88.1%).
All young people in review studies were
recruited based on their suicide attempt,
deliberate self-harm and suicide ideation
at current state or within 72 hours to three
months. Three studies had included criteria
for teenagers with cormorbid mental health
disorders as depression (6, 8, 28) or anxiety
2.6. Data abstraction
Datawereextractedusingastandardized
data extraction form in Microsoft Excel
included study: author, year, country,
study design, population, intervention,
comparison, outcomes, major findings
relevant to the PICO. Two reviewers
checked the accuracy of the input data.
2.7. Synthesis
A descriptive analysis of included
studies is provided in the text narrative and
summarized in the PRISMA flow diagram
(Figure 1).
Journal of Nursing Science - Vol. 04 - No. 01
101
RESEARCH ARTICLE
and posttraumatic stress disorder (6).
Cognitive Behavior Therapy (AO-CBT),
Family-enhanced Nondirective Supportive
Therapy (FE-NST). Please see Table 1.
Caregivers, who were recruited in review
studies, were defined coherently as parents
(biological or adoptive), primary career
(6), primary caretaking parent, caregivers
– hereafter referred to as parents (26),
primary caregiver other than mother or
father as aunt, grandmother, step mother,
older sibling (8), caregivers, legal guardian
with whom the adolescent resided (11).
However, the most common and important
for caregivers that they had to live together
and supported for teenagers with suicide
risk during the intervention and follow-up.
One study conducted by Spirito et al., (28)
provided intervention for both parents and
their children who got diagnosed together
with major depressive disorders.
3.3. Intervention programs content
Overall, doses of family psychoeducation
treatment in review studies vary from four
to twenty sessions within one to two hours
per session in the duration of four to sixteen
weeks, only one study provided one single
session.
RAP-P intervention program was
delivered for parents of young adults
through four sessions during 4-8 weeks
with two hours each session. The
intervention was mainly focus on stress
management, adolescent development,
strategies to promote family harmony
and to manage conflict, information to
enhance parents understanding of suicidal
behavior and practical strategies to help
their children minimize their self-injurious
behavior (6). SAFETY Program included
20 session over 12 weeks with 9 weeks
individual intervention for caregivers and
children, then 3 final week brought youths,
parents and therapists together to practice
safety skills and behavior skills. SAFETY
Program’s contents were psychoeducation,
identify youth and family strengths,
emotional thermometer, “safety plan” for
reducing “emotional temperature” and
suicide attempt risk and “Safety Plan Card”
(26, 27). Two studies assessed at the same
time points: baseline-assessments after
ED-discharge, 3-month post-treatment
assessments, and at 6-months, but in
studied conducted in 2017 Asarnow et al.,
added one more time point to measure the
effectiveness at 12 month postbaseline
(26).
Studies examined the impact of range
of interventions, including individual (for
only parent and adolescence) or both
adolescence and their caregiver in conjoint
sessions. Intervention programs which
were delivered for both adolescences and
caregivers together were Resourceful
Adolescent Parent Program (RAP-P),
Family-Based Crisis Intervention (FCBI).
Safe Alternatives for Teens & Youths
(SAFETY Program) and Attachment-based
Family Therapy (ABFT) were decorated to
delivery separate parents and adolescence
mostly sessions then therapists worked with
both parents and teens in final sessions.
Only
Parent-Adolescent-Cognitive
Behavior Therapy (PA-CBT) was delivered
separately during the intervention program,
however all individual sessions concluded
with a conjoint meeting between parent and
teen to enhance positive communication
and a review of the skills learned. Control
conditions included treatment as usual
(TAU) e.g. routine care, enhanced TAU e.g.
an in-clinic parent education session, follow
by at least 3 telephone calls supporting
motivation or active control group with other
intervention program as Adolescent Only
To enhance family functioning in term
of support teen reduce suicide risk and
understand from adolescences’ point of
view about different treatments, researchers
delivered ABFT and FE-NST during 16
102
Journal of Nursing Science - Vol. 04 - No. 01
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
suicidal and depressive symptoms. ABFT
primarily relies on joint parent–teen
sessions that address the rupture and
enhance the adolescent’s confidence in a
parent’s availability. The therapist provides
a supportive and reflective listener who
encourages the adolescent to explore and
clarify distressing thoughts and feelings
in FE-NST. FE-NST was included five
sessions for parents with contents in joint
parent–teen safety planning and parent
psychoeducation about their adolescent’s
depressive and suicidal symptoms. The
measurements of suicidal and depressive
symptoms were collected monthly through
Week 16 (posttreatment).
Difference with other interventions were
delivered from four weeks to 12 weeks,
FBCI was a novel, single-session ED-based
intervention for suicidal adolescents and
their families (11). During 60-90 minutes
FBCI program, clinician helped the suicidal
adolescent and their parents develop a joint
crisis narrative of the problem and taught
them cognitive behavioral skill building,
therapeutic readiness, psycho-education
about depression, and safety planning.
The outcome was assessed at five time
points over the course of the study: before
randomization, after evaluation/intervention
in the ED, and via telephone at 3 days, 1
week, and 1-month after the ED visit.
3.4. Study quality
It is interesting to get more information
about the comparison of two interventions
between PA-CBT and AO-CBT. Moreover,
bothparentsandtheirchildrenhaddiagnosis
of MDE. Two programs were contained 12
sessions over 12 weeks. Adolescence who
participated in AO-CBT and PA-CBT, will
received safety plans, core skills including
problem solving, cognitive restructuring,
affect regulation, behavioral activation,
relapse prevention. Parents in the AO-
CBT participated in end of most sessions,
especially in safety discussion sessions.
Similarity, the adolescent sessions in PA-
CBT were essentially the same as those
in AO-CBT. Parent sessions comprised
the same skills as their children’, using
the same format for better communication
between them about skills. In the PA-CBT
condition, all individual sessions concluded
with a conjoint meeting between parent and
teen. The check-in included an exchange of
positive comments between the parent and
teen to enhance positive communication
and a review of the skills learned (28). Then
they all completed all research evaluations
at four time points: baseline, mid-treatment
The risk ofbiaswithin studiesis displayed
in Table 2. All studies applied an appropriate
study method to address a focused
research question. The included studies
were critically appraised for methodological
quality and risk of bias based on “Cochrane
Risk of Bias Tool” (29).The majority of
these studies used random sequence
generation and used adequate allocation
concealment strategies (6, 8, 11, 26). Of
the six studies that four assessed outcomes
by interview face to face, one study used
self-report and the other one applied both
self-report and interview via telephone.
Almost studies reported assessor blinding
(6, 8, 11, 26, 27). All six studies reported
conducting intention-to-treat (ITT) analysis.
Four studies reported less than 15% drop
out and were classed as low risk (27). Two
interventions included SAFETY program
(26) and FBCI (11) which were assessed
as low risk of bias for all domains.
3.5. Effectiveness of the intervention
For the primary outcome of reduce
suicide ideation, suicide thought, suicide
behavior in adolescences, all six studies
Journal of Nursing Science - Vol. 04 - No. 01
103
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 interventionphaseoneforemotionaldistress
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
attempt risk of 0.33 in the E-TAU group at
the3-monthfollow-uppointandbetween3-6
months, one suicide attempt in SAFETY but
seven suicide attempts in E-TAU (26). On
average, adolescents reported a significant
decrease in suicidal ideation from the
beginning to end of treatment. On average,
this rate of change corresponded to a total
decline of 29.26 points on the Adolescents’
suicidal ideation scale (SIQ-JR) between
baseline and posttreatment. Adolescents
from traditionally underserved (non-White
or lower income) families showed greater
reductions in suicidal ideation in both
treatments (8). Finally, no completed suicide
was reported in all six studies during the
study period in either condition.
Secondary outcome in enhancing family
relationship refer to family functioning
were found in two studies (6, 8). Family
focused interventions had showed positive
improvement in family functioning and thus
reduce adolescent depressive symptoms
in both studies. However, this positive
result had no significant relationship with
reduction in suicidality of teenagers.
Regarding to the measurement tools
to assess suicide risk of adolescence,
researchers
applied
six
different
questionnaires in six studies. Australian
researchers (6) used Adolescent Suicide
Questionnaire-Revised (ASQ-R) which was
developed from the original ASQ widely
applied with Australian secondary school
students. ASQ-R included nine items to
document suicide ideation, plans, and
threats, deliberate self-harm, and suicide
attempts. Four items measured frequency
(0=never to 3=all of the time), and 5 items
measured recency (0=never, 1=in the last
12 months, to 3=in the last month). These
items were summed to form a total ASQ-R
score for each adolescent at each time
point (Cronbach alpha=0.74). Four studies
in United States applied four differences
In relation to suicide attempt or self-
harm, reduction of admission rate had been
reported in four studies during and after the
intervention programs. Four youths (12.5%
of the sample) were seen in the ED and
hospitalized during the 3-month follow-up
period due to deliberate self-harm (27).
Continue their study of SAFETY program,
the authors reported the probability of
survival to the 3-month posttreatment
104
Journal of Nursing Science - Vol. 04 - No. 01
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
applied Beck Suicide Scale (BSS) for both
adolescents and parents in their study.
Internal consistency for this sample on
the BSS were excellent (a=0.90 for both
adolescent measures; a=0.93 and 0.95 for
parents, respectively).
(Columbia Suicide History Form) was
applied for coding timing, method, and
lethality of suicidal/self-harm behavior.
Research team have previously developed
quality assurance procedures indicated
strong quality (Mean =1.2, SD=0.54, 3-point
scale 1=good to 3=poor). In addition, to
assess suicidal behavior and ideation and
passive suicidal ideation authors used self-
report on the 17-item HarkavyAsnis Suicide
Survey (HASS) (27). However, in the next
RCTs in 2017, authors applied Columbia
Suicide Severity Rating Scale (C-SSRS)
to assess suicide attempt and self-harm
which contains probes and scales for rating
severity of suicidal behavior plus a parallel
scale assessing nonsuicidal self-injury
(NSSI) and the Suicide History Interview
(26). Suicidal Ideation Questionnaire-
Junior (SIQ-JR) was employed to assess
adolescents’ suicidal ideation by Zisk et al.,
(8). This is a 15-item self-report measure
with statements such as “I thought about
killing myself” and “I thought about how I
would kill myself.” Each item is rated on a
7-point scale that assesses the frequency
of these suicidal thoughts (1=absence of
the thought,7=the thought has occurred
almost every day for the past month).
Authors reported in their current sample,
the SIQ-JR demonstrated good internal
consistency (Cronbach alpha = .84). In
study of Wharff et al., they used Reasons
for Living Inventory forAdolescents (RFL-A)
to measure the presence of adaptive
qualities and associated protective factors
of suicidal adolescent populations (11). The
RFL-A is a 32-item self-reports contains 5
subscales: family alliance, suicide-related
concerns, peer acceptance and support,
self-acceptance, and future optimism. The
RFL-A had reported high levels of internal
consistency with respect to subscales and
4. DISCUSSION
This review examined six studies of
family-based intervention designed to
reduce suicide risks among adolescences.
All of studies were conducted in high
income countries and participants with
suicide ideations or attempts were
referred from ED and psychiatric hospitals.
Intervention settings, content, therapists
were varied across programs. The average
of participants from 11 to 18 years old
with female dominant, suggesting that
the finding from the interventions may be
most applicable to young people under 18
years old and their caregivers. Overall, all
the programs identified in review reported
significant effects on suicidal ideation,
suicide attempts or deliberate self-harm,
especially no completed suicide during the
intervention and follow-up period. Small
to large effect sizes were reported by the
effective programs with short- and long-
term effectiveness evidence. This result
could be explained due to the drop-out
rate more than 15% in more than a half
of studies. This highlights the importance
of sufficiently powering studies to detect
expected intervention effects.
Family had strong evidence of ability to
provide a safe and containing environment
for their child during hospitalization and
in the community (11, 13). Intervention
included both individual and conjoint
meeting reported effects for both suicide
ideation and attempts which maintained
during follow-up process. However, very
Journal of Nursing Science - Vol. 04 - No. 01
105
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-
face interview. As a result, the quality of the
data collection may vary between studies.
There is a suggestion for further practical
training program to enhance general
nurses’ abilities of suicide risk identification,
assessment and manage this population.
Finally, our searching criteria did not include
non-English language so that there might
be other effective programs not appear in
our result.
This review suggested strong evidence
for implementation of family-based suicide
prevention program in ED, psychiatric
hospital, pediatric hospital and home of
participants. All of these settings were
found to be effective for adolescences with
suicide ideation and attempts. The most
effectiveness and applicability program
in this review was FBCI which was 60-
90
minutes
single-session-ED-based
for adolescents and their families in ED
setting (11). This result suggested a widely
application for every teenager who admitted
to the ED due to suicide behaviors. Family-
based intervention especially in crisis offer a
promising alternative to traditional inpatient
care while enhance family empowerment
and adhering to objective of the growing
community-based movement (11). In
additional, to reduce barriers to treatment
attendanceandtostrengthenunderstanding
of the home and community environment,
SAFETY program was strongly suggested
for further implementation at teenagers’
home. These results show a good strategy
which target suicide prevention and early
intervention program for young people and
their family members during crisis in ED
or psychiatric setting and at participants’
home. With multi approaches for selective
and indicated interventions in this review,
there is a need to further explore universal
program in this population.
5. CONCLUSION
Even though there are not many family-
based suicide prevention programs for
adolescences with suicidality available
for the implementation in hospital setting
or at participants’ home, there is powerful
evidence on their efficacy. The intervention
implementation process should take into
account intervention specifics, development
process, culture context where intervention
is going to develop and characteristics of
environment where the intervention should
beimplemented. Inaddition, theintervention
must be handed by healthcare professional
that has appropriate knowledge and skill
for prevention, management and promotion
of suicidality and mental health disorders.
There is a need for investing in nursing
education to ensure the best care and
support strategy for reducing suicide rate of
adolescences.
6. IMPLICATION
There are some limitations to the current
review that should be addressed. This
review excluded studies did not include
suicide outcome measures but may have
had positive effects as seeking behavior,
literacy and attitudes. It is also possible
This review provided a robust evidence
for implication of family-based suicide
prevention program for every teenager who
admitted to the ED, psychiatric hospital,
pediatric hospital due to suicide behaviors.
106
Journal of Nursing Science - Vol. 04 - No. 01
RESEARCH ARTICLE
Family-based
intervention
especially Costs and Policy Implications. Suicide and
in crisis offer a promising alternative to Life-Threatening Behavior. 2016;46(3):352-
62.
5. Brent DA, Greenhill LL, Compton S,
traditional inpatient care while enhance
family empowerment and adhering to
objective of the growing community-based
movement. These results show a good
strategy which target suicide prevention
and early intervention program for young
people and their family members during
crisis in ED or psychiatric setting and at
participants’ home. Finally, all interveners
were very little nurses’ involvement
while nursing professionals are first-line
gatekeepers of patients reduce the risk
for health condition. Suicide is an issue
that illustrates the needs for holistic care
which involves discovering the purpose and
meaning of the suicidal patients’ lives and
their families, and helping to integrate body,
mind and spirit (30). In addition, the core
concept of nursing education is holistic care
and daily nursing practice offer nurses the
most opportunities to identify early signs
of mental distress or suicidal ideations in
different medical settings. More effort would
be needed for nurses to integrate suicide
prevention into clinical practice and nursing
education.
Emslie G, Wells K, Walkup JT, et al. The
Treatment ofAdolescent SuicideAttempters
Study (TASA): Predictors of Suicidal Events
in an Open Treatment Trial. Journal of the
American Academy of Child & Adolescent
Psychiatry. 2009;48(10):987-96.
6. Pineda J, Dadds MR. Family
intervention for adolescents with suicidal
behavior: a randomized controlled trial
and mediation analysis. Journal of the
AmericanAcademy of Child andAdolescent
Psychiatry. 2013;52(8):851-62.
7. Newman B, Newman P, Griffen S,
O’Connor K, Spas J. The relationship of
social support to depressive symptoms
during the transition to high school.
Adolescence. 2007;42(167):441-59.
8. Zisk A, Abbott CH, Bounoua N,
Diamond GS, Kobak R. Parent-teen
communication predicts treatment benefit
for depressed and suicidal adolescents.
Journal of consulting and clinical
psychology. 2019;87(12):1137.
9. Cottrell DJ, Wright-Hughes A,
Collinson M, Boston P, Eisler I, Fortune
S, et al. Effectiveness of systemic family
therapy versus treatment as usual for young
people after self-harm: a pragmatic, phase
3, multicentre, randomised controlled trial.
The Lancet Psychiatry. 2018;5(3):203-16.
REFERENES
1. WHO. Suicide in the world: Global
Health Estimates. 2019.
2. Evans E, Hawton K, Rodham
K, Deeks J. The prevalence of suicidal
phenomena in adolescents: a systematic
review of population-based studies. Suicide
Life Threat Behav. 2005;35(3):239-50.
10. Sun F-K, Long A. A theory to guide
families and carers of people who are at
risk of suicide. Journal of clinical nursing.
2008;17(14):1939.
3. Cutcliffe JR, Stevenson C. Never
the twain? Reconciling national suicide
prevention strategies with the practice,
educational, and policy needs of mental
health nurses (Part one). Int J Ment Health
Nurs. 2008;17(5):341-50.
11. Wharff EA, Ginnis KB, Ross AM,
White EM, White MT, Forbes PW. Family-
Based Crisis Intervention With Suicidal
Adolescents: A Randomized Clinical Trial.
Pediatric emergency care. 2019;35(3):170-
5.
4. Shepard DS, Gurewich D, Lwin
AK, Reed Jr GA, Silverman MM. Suicide
and Suicidal Attempts in the United States:
12. Sun F-K, LongA, Huang X-Y, Chiang
Journal of Nursing Science - Vol. 04 - No. 01
107
RESEARCH ARTICLE
C-Y. A grounded theory study of action/ EClinicalMedicine. 2018;4:52-91.
interaction strategies used when Taiwanese
families provide care for formerly suicidal
patients. Public health nursing (Boston,
Mass). 2009;26(6):543.
20. Diamond GS, Wintersteen MB,
Brown GK, Diamond GM, Gallop R, Shelef
K, et al. Attachment-Based Family Therapy
for Adolescents with Suicidal Ideation: A
13. Sun F-K, Chiang C-Y, Lin Y-H, Randomized Controlled Trial. Journal of the
Chen T-B. Short-term effects of a suicide American Academy of Child & Adolescent
education intervention for family caregivers Psychiatry. 2010;49(2):122-31.
of people who are suicidal. Journal of
clinical nursing. 2012;23(1-2):91.
21. Huey SJ, Henggeler SW, Rowland
MD, Halliday-Boykins CA, Cunningham PB,
14. Wharff EA, Ginnis KB, Ross AM. Pickrel SG, et al. Multisystemic Therapy
Family-based Crisis Intervention with Effects on Attempted Suicide by Youths
Suicidal Adolescents in the Emergency Presenting
Psychiatric
Emergencies.
Room: Pilot Study. Social Work. Journal of the American Academy of Child
A
2012;57(2):133-43.
& Adolescent Psychiatry. 2004;43(2):183-
90.
15. HuntIM,KapurN,WebbR,Robinson
J, Burns J, Shaw J, et al. Suicide in recently
22. Husky MM, Olfson M, He J-p,
discharged psychiatric patients: a case- Nock MK, Swanson SA, Merikangas KR.
control study. Psychological medicine. Twelve-Month Suicidal Symptoms and Use
2009;39(3):443.
of Services Among Adolescents: Results
From the National Comorbidity Survey.
Psychiatric Services. 2012.
16. Milner AJ, Carter G, Pirkis J,
Robinson J, Spittal MJ. Letters, green cards,
telephone calls and postcards: systematic
23. Liberati A, Altman DG, Tetzlaff
and meta-analytic review of brief contact J, Mulrow C, Gøtzsche PC, Ioannidis
interventions for reducing self-harm, suicide JPA, et al. The PRISMA statement for
attempts and suicide. The British journal of reporting systematic reviews and meta-
psychiatry : the journal of mental science. analyses of studies that evaluate health
2015;206(3):184.
care interventions: explanation and
elaboration. Annals of internal medicine.
2009;151(4):W65.
17. Valérie Le M, Christophe L, Michel
W, Sofian B. Viewpoint: Toward Involvement
of Caregivers in Suicide Prevention
24. Higgins JP, Altman DG. Assessing
Strategies; Ethical Issues and Perspectives. Risk of Bias in Included Studies. Cochrane
Frontiers in Psychology. 2018;9.
Handbook for Systematic Reviews of
Interventions2008. p. 187-241.
18. Nock MK, Green JG, Hwang I,
McLaughlin KA, Sampson NA, Zaslavsky
25. Hawton K, Witt KG, Taylor Salisbury
AM, et al. Prevalence, correlates, and TL, Arensman E, Gunnell D, Townsend E,
treatment of lifetime suicidal behavior et al. Interventions for self-harm in children
among adolescents: results from the and adolescents. The Cochrane database
National Comorbidity Survey Replication of systematic reviews. 2015(12):Cd012013.
Adolescent Supplement. JAMA Psychiatry.
2013;70(3):300-10.
26. Asarnow JR, Hughes JL, Babeva
KN, Sugar CA. Cognitive-Behavioral Family
19. Jo R, Eleanor B, Katrina W, Treatment for SuicideAttempt Prevention:A
Nina S, Allison M, Dianne C, et al. What Randomized Controlled Trial. Journal of the
Works in Youth Suicide Prevention? A American Academy of Child & Adolescent
Systematic Review and Meta-Analysis. Psychiatry. 2017;56(6):506-14.
108
Journal of Nursing Science - Vol. 04 - No. 01
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, Gøtzsche
PC, Jüni P, Moher D, Oxman AD, et al. The
Cochrane Collaboration’s tool for assessing
risk of bias in randomised trials. BMJ.
2011;343:d5928.
Cognitive-Behavioral Family Treatment for
Adolescent Suicide Attempters. Journal of
Clinical Child & Adolescent Psychology.
2015;44(1):194-203.
28. Spirito A, Wolff JC, Seaboyer LM,
Hunt J, Esposito-Smythers C, Nugent N,
et al. Concurrent treatment for adolescent
and parent depressed mood and suicidality:
feasibility, acceptability, and preliminary
30. Boswell C, Cannon SB, Miller J.
Students’ perceptions of holistic nursing
care. Nursing education perspectives.
2013;34(5):329-33.
Figure 1: Prisma flow chart
Records identified through
database searching
Embase = 317
Additional records identified
through other sources
(n =15)
MEDLINE = 57
Cochrane = 62
Records after duplicates removed
(n = 422)
Records excluded (n = 262)
1. Not included caregiver
2. Not an RCT
3. Irrelevant studies
4. Systematic reviews or meta-
analysis
Records screened
(n = 422)
Full-text articles excluded (n =
154)
1. No data on suicide outcomes
(n=66)
Full-text articles
assessed for eligibility
(n = 160)
2. Research protocol (n=5)
Studies included in
review
(n = 06)
Journal of Nursing Science - Vol. 04 - No. 01
109
RESEARCH ARTICLE
Table 2: Characteristic of included studies
N
1
Author/
Country
Design/
Participant
Criteria
Intervention
Measurements
Outcomes
Jane Pineda,
Mark R.
Dadds, 2013,
Australia
RCT;
pre-treatment,
3m, 6m
Inclusion:
Adolescents
12-17 ys;
depression,
PTSD, anxiety months interactive
SI, SA or DSH psychoeducation
within the last
2 months; one
parent (biological
or adoptive) was
primary carer;
*RAP-P: 4
sessions, 2h/
session per
+ Adolescence:
Adolescent
Suicide
Questionnaire-
Revised
*PO:
adolescent
suicide-self
harm risk and
psychiatric
impairment and
the
1-2w up to 2.5
N=48;
I=24
C=24
(ASQ-R);
program for
parents
Strengths and
Difficulties
Questionnaire
(SDQ)
+ Parents: SDQ
*Clinician:
*SO: family
adjustment
*Routine
Care: crisis
management,
safety planning,
individual
an average or
above-average
intellectual level;
basic English
Health of
the Nation
psychoeducation, Outcomes Scale
language abilities
nonspecific
counseling,
for Children and
Adolescents
Exclusion:
psychosis;
developmental behavior therapy,
supportive
therapy, cognitive-
(HoNOSCA)
Family
disorders
pharmacological
treatment
Assessment
Device (FAD)
RAP-P + RC
Delivery together
parent and
adolescence
RC
No parents’
involvement
2
Joan
RCT pilot;
Inclusion: youths
11-18ys; SA
in past 3m;
stable living
situation; parents
participate.
Length: 20
sessions over 12
weeks (incl: 1×
family session
then
individual (16 x
youth-only &
parent-only), then
up to 16×family
session)
+ Baseline,
3-months:
Diagnostic
Interview
Schedule for
Children &
Adolescents
(NIMH DISC
IV); suicidal
behaviors
*PO: reduce
suicidal behavior
*SO: reduce
youth & parent
depression,
hopelessness,
social
Rosenbaum baseline, 3m,
Asarnow et 6m, follow-up
al., 2015;
USA
N=35;
no control
group
Exclusion:
no contact
information
available for
follow-up;
psychosis;
substance
abuse/
dependence;
not English-
speaking;
no family to
participate
adjustment
(Columbia
* SAFETY
Program
1)
Suicide History
Form); Harkavy
Asnis Suicide
psychoeducation Survey (HASS)
2) identify youth Youth & parent:
and family
strengths;
3) emotional
thermometer; 4)
Center for
Epidemiological
Studies-
Depression
“safety plan” for Scale (CES-D),
reducing Beck
110
Journal of Nursing Science - Vol. 04 - No. 01
RESEARCH ARTICLE
“emotional
temperature” and
SA-risk; 5) “Safety
Plan Card”
Developed by
Henggeler (2002)
Hopelessness
Scale (BHS);
Social
Adjustment
Scale-Self
Report for
Youth (SAS-
SAFETY Program SR), Treatment
Delivery individual
then together
parent and
Satisfaction
Scale,The
Service
Assessment for
Children and
Adolescents
(SACA)
adolescence
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
al., 2017;
USA
6m, 12m;
or NSSI (past
3m); repetitive
SH (≥3 lifetime);
stable family
situation,
3m; skill-building
based on CBFA; (C-SSRS); Mood
3 final weeks & psychosis
brought youths, disorders (DISC
parents, therapists IV); The Service
Rating Scale
N = 42
I=20;
C=22
one parent
participated
together to
practice “safety”
skills and
behaviors skill
(consolidation,
relapse
Assessment for
Children and
Adolescents
(SACA);
Center for
Epidemiological
Studies–
Exclusion:
symptoms
interfering
(psychosis,
prevention,
substance use); linkage to needed
Depression
Scale (CES-D);
The Drug Use
Screening
inability to speak
services) 2
therapists for 1
family, one for
youth, other for
parents;
English
Inventory
(DUSI); Youth
Self-Report
(YSR) and
SAFETY Program
Delivery
9 sessions
parent report
individual parent (Child Behavior
and teen, 3
session together
parent and
Checklist
(CBCL)
adolescence
*E-TAU: treatment
as usual
enhanced by an
in-clinic parent
Journal of Nursing Science - Vol. 04 - No. 01
111
RESEARCH ARTICLE
education
session, follow
by ≥ 3 telephone
calls supporting
motivation; actions
to obtain follow-up
treatment.
4
Abigail Zisk
et al., 2019,
USA
RCT,
monthly
assessments
through
*Inclusion: 12-
18ys, severe
SI ≥ 31 SIQ-
JR; moderate
16 weeks, five
tasks
ABFT:
conversations
+ Baseline:
cooperative
communication
(GPACS),
PO: suicidal
and depressive
symptoms
week 16
(posttreatment)
N=129
ABFT=66;
FE-NST=63
depression ≥ 20 about perceived
parent–
adolescent
BDI-II
attachment
ruptures,
dyads were
video-recorded
10-min conflict
discussion, Self-
Report of Family
Functioning
Conflict scale
(SRFF),
*Exclusion: risk
of harm to self/
others, psychotic
symptoms,
improvement
in the parent
– adolescent
relationship.
severe
impairment
in cognitive
FE-NST: safety
planning,
functioning;
antidepressant
medication
understanding
adolescent
depression,
+ Monthly
symptom
assessments:
within 3 weeks assessing suicide BDI-II, Suicidal
of the initial
assessment; not
willing caregiver
to participate; not
speak English
risk, enhancing
advocacy
and resource
development,
and increasing
problem-solving
Ideation
Questionnaire-
Junior SIQ-JR
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.
Wharff et al.,
RCT;
pre, post,
*Inclusion:
13-18ys, SA
FBCI: one
session, 60-
Reasons for
Living Inventory
*PO: suicidality,
family
2019, USA 3days, 1week, in 72 hours, a 90mins, research for Adolescents empowerment
1m
N=142
parent noted
direct behaviors
indicating
clinician helped (RFL-A), Family
the suicidal
adolescent
and parents
develop a joint
crisis narrative
of the problem
and taught
Empowerment
Scale (FES)
Client
Satisfaction
Questionnaire
(CSQ-8)
*SE: parent
satisfaction
suicidality,
presence of
a consenting
parent/ legal
guardian with
whom the
Parents/
them cognitive
behavioral
skill building,
therapeutic
guardians
adolescent
answered two
questions at
each follow-up
time point.:
resided, parent/
guardian agreed
to participate.
readiness,
112
Journal of Nursing Science - Vol. 04 - No. 01
RESEARCH ARTICLE
Exclusion: lack psycho-education
“Since your
initial visit to the
ED, has your
child required
another crisis
evaluation?”
and “Since
your initial visit
to the ED, has
your child been
psychiatrically
hospitalized
fluency English,
not medically
stable, cognitive
limitations,
about depression,
and safety
planning
active psychosis,
required physical
or medication
restraint in the
ED
FBCI
Delivery together
parent and
adolescence
TAU: standard
psychiatric
again?”
evaluation and
clinical/discharge
recommendations
6
Anthony
Spirito et al.,
2015, Island mid-treatment
(6w), end of
RCT;
baseline,
Inclusion:
adolescent and
parent dyads
lived together,
spoke English.
Adolescence:
11–17 ys; current
MDE; Clinical
Depression
12 sessions over + Adolescence: *PO: suicidality,
Beck Suicide
Scale
depression
12 weeks
(BSS), BDI-II,
Hopelessness
Scale for
Children (HSC),
The McLean
Screening
Instrument
for Borderline
Personality
Disorder (MSI-
BPD), The
Childhood
Trauma
Questionnaire
(CTQ)
+ Parent: BSS,
BDI-II, Beck
Hopelessness
Scale (BHS),
MSI-BPD,
+ Middle + End
treatment of
PA-CBT : Client
Satisfaction
Questionnaire
(CSQ), The
Working Alliance
Inventory (WAI)
+ Clinician rate:
K-SADS &
*AO-CBT: safety
plans, core skills
including problem
solving, cognitive
restructuring,
affect regulation,
behavioral
treatment
(12w), 48w
follow-up
N = 24
PA-CBT = 16 Severity Rating
AO-CBT = 08 Scale (CDRS)
>=65; current or
past suicidality
activation.
* PA-CBT: same
as in AO-CBT.
Parent sessions
comprised the
same skills
as adolescent
sessions.
Medication
management:
met with the
study psychiatrist
for medication
management.
(BDI-II) or
(K-SADS-P)
Parent: either
current or past
MDE; BDI >= 15
with a current
MDE, >= 10 with
a past MDE.
Exclusion:
bipolar disorder,
substance
use disorder,
developmental/
cognitive delays,
psychosis
PA-CBT
Intervention
for parent and
adolescence
separate but each
session had one
conjoint meeting.
The Structured
Clinical Interview
for DSM-IV –
Patient Version
(SCID-I/P);
AO-CBT:
Delivery only for
Adolescents.
Parents
participated only in
the end of-session
and involved in
safety concerns
sessions
CDRS
Journal of Nursing Science - Vol. 04 - No. 01
113
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
than
15%
Blinding of
participants
and
Random
Study sequence
generation
Blinding of
outcome
Ascertainment
of DSH
ITT analysis
undertaken
assessment drop-out
repetition
personnel
rate
(6)
Yes
NR
NR
Yes
No
No
No
No
Yes
Yes
NR
Yes
No
Yes
Yes
Yes
Yes
Yes
Interview
Interview
Interview
Self-report
(27)
(28)
(26)
Unclear
Yes
Self-report +
interview via
phone
(11)
Yes
Yes
Yes
Yes
Yes
(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
17 trang
14/04/2022
1620
Bạn đang xem tài liệu "Family-based intervention for suicide prevention in adolescences: A systematic review", để tải tài liệu gốc về máy hãy click vào nút Download ở trên
File đính kèm:
- family_based_intervention_for_suicide_prevention_in_adolesce.pdf
