Participant characteristics

In the 39 trials that recorded information on age, the average age of participants at randomisation was 30.9 years (SD 4.6). Twenty trials included a small number of adolescent participants (i.e., under 18 years of age at randomisation) (Carter 2005; Dubois 1999; Evans 1999b; Gibbons 1978; Hassanian‐Moghaddam 2011; Hatcher 2016a; Hatcher 2015; Hatcher 2011; Hawton 1987a; Husain 2014; Hvid 2011; Marasinghe 2012; McLeavey 1994; Morthorst 2012; Priebe 2012; Salkovskis 1990; Slee 2008; Van der Sande 1997a; Van Heeringen 1995; Wei 2013). However, investigators did not record the precise number in any of them. As the majority of participants in these trials were adults, we included them in the present review rather than in the related review specific to interventions for children and adolescents (i.e., Hawton 2015a). The majority of the sample was female in the 46 trials that recorded information on sex (k = 46; mean 69.2%), reflecting the typical pattern for SH (Hawton 2008).

Diagnosis

In all trials, a recent episode of SH was a requirement for trial entry. SH includes intentional acts of self‐harm (i.e., self‐poisoning or self‐injury) and not acts such as recreational use of drugs that may result in accidental harm.

A history of multiple episodes of SH was a requirement for participation in 13 trials (Evans 1999b; Gratz 2006; Gratz 2014; Harned 2014; Liberman 1981; Linehan 1991; Linehan 2006; McMain 2009; Priebe 2012; Salkovskis 1990; Torhorst 1988; Tyrer 2003; Weinberg 2006). For an additional 28 trials, over half the sample had a history of multiple episodes of SH (Allard 1992; Bateman 2009; Beautrais 2010; Bennewith 2002; Brown 2005; Carter 2005; Cedereke 2002; Crawford 2010; Davidson 2014; Dubois 1999; Gibbons 1978; Guthrie 2001; Hatcher 2016a; Hatcher 2015; Hatcher 2011; Husain 2014; Kapur 2013a; Marasinghe 2012; McAuliffe 2014; McLeavey 1994; Morthorst 2012; Patsiokas 1985; Slee 2008; Stewart 2009; Tapolaa 2010; Turner 2000; Wei 2013; Welu 1977). In four further trials, just under half of the sample had a history of multiple episodes of SH (Clarke 2002: 47.0%; Evans 1999a: 47.6%; Kawanishi 2014: 49.2%; Van der Sande 1997a: 46.3%). We present the proportion with a prior history of SH in the remaining eight trials in Table 1. Morgan 1993 excluded those with a history of multiple episodes of SH from participation, whilst Torhorst 1987 provided no information on the proportion of the sample with a history of multiple episodes of SH.

In around half of the included trials (k = 25; 45.4%), the authors stated either within the trial report or through correspondence that they included participants irrespective of whether or not the episode of SH involved suicidal intent (Bateman 2009; Beautrais 2010; Bennewith 2002; Clarke 2002; Davidson 2014; Fleischmann 2008; Harned 2014; Hatcher 2016a; Hatcher 2015; Hatcher 2011; Hawton 1981; Hawton 1987a; Hvid 2011; Kapur 2013a; Liberman 1981; Linehan 2006; McAuliffe 2014; McMain 2009; Patsiokas 1985; Slee 2008; Tapolaa 2010; Torhorst 1987; Turner 2000; Tyrer 2003; Van Heeringen 1995; Waterhouse 1990). Seven trials included participants following a 'suicide attempt' (i.e., suggestive of evidence of suicidal intent) (Allard 1992; Cedereke 2002; Morthorst 2012; Salkovskis 1990; Torhorst 1988; Van der Sande 1997a; Wei 2013). A further five trials included participants only if there had been evidence of suicidal intent (Brown 2005; Kawanishi 2014; Marasinghe 2012; Stewart 2009; Welu 1977), whilst in an additional two, the majority of participants (76.5% and 74.0% respectively) expressed a wish to die (Guthrie 2001; Husain 2014). Gratz 2014 included participants only if there was no evidence of suicidal intent, whilst only 2.0% in one trial expressed a wish to die (Vaiva 2006). Thirteen trials did not report information on suicidal intent (Carter 2005; Crawford 2010; Dubois 1999; Evans 1999a; Evans 1999b; Gibbons 1978; Gratz 2006; Hassanian‐Moghaddam 2011; Linehan 1991; McLeavey 1994; Morgan 1993; Priebe 2012; Weinberg 2006).

Twenty‐five trials did not report information on the methods of SH for the index episode (Allard 1992; Bateman 2009; Cedereke 2002; Davidson 2014; Dubois 1999; Evans 1999b; Fleischmann 2008; Gratz 2006; Gratz 2014; Hvid 2011; Kapur 2013a; Linehan 1991; Linehan 2006; Marasinghe 2012; McMain 2009; Morthorst 2012; Patsiokas 1985; Priebe 2012; Salkovskis 1990; Stewart 2009; Tapolaa 2010; Turner 2000; Tyrer 2003; Wei 2013; Weinberg 2006). One trial provided information on the methods used in all episodes of SH (including the index episode) in the two years preceding trial entry (Liberman 1981). A total of 55.7% of these episodes involved self‐poisoning and 44.3% involved self‐injury. One additional trial provided information on methods used in the three months prior to trial entry with a total of 61 (67.8%) participants in this trial engaging in self‐injury at least once over this period; however, investigators did not specify the methods that the remaining 29 participants used for SH (Slee 2008). We present methods of SH for the remaining 28 trials in Table 2. In these trials, the majority of participants had engaged in self‐poisoning (k = 28; 79.9%). Two trials included only those who engaged in self‐injury (Harned 2014; Welu 1977), whilst in a further trial the majority of participants (75.6%) had engaged in self‐poisoning using pesticides (Husain 2014).

Comorbidities

We present information on current psychiatric diagnoses for all 55 trials in Table 3. Eight trials focused specifically on participants diagnosed with borderline personality disorder (Bateman 2009; Gratz 2006; Gratz 2014; Linehan 1991; Linehan 2006; McMain 2009; Turner 2000; Weinberg 2006), three focused on participants diagnosed with any personality disorder (Davidson 2014; Evans 1999b; Priebe 2012), one focused specifically on participants diagnosed with alcohol use (Crawford 2010), and one focused on participants with comorbid post‐traumatic stress disorder and borderline personality disorder (Harned 2014).

Details on comorbid diagnoses were not reported in the majority of trials (k = 49; 89.1%) (Allard 1992; Bateman 2009; Beautrais 2010; Bennewith 2002; Cedereke 2002; Clarke 2002; Crawford 2010; Dubois 1999; Evans 1999a; Evans 1999b; Fleischmann 2008; Gibbons 1978; Gratz 2006; Guthrie 2001; Harned 2014; Hassanian‐Moghaddam 2011; Hatcher 2016a; Hatcher 2015; Hatcher 2011; Hawton 1981; Hawton 1987a; Husain 2014; Hvid 2011; Kapur 2013a; Kawanishi 2014; Liberman 1981; Linehan 1991; Linehan 2006; Marasinghe 2012; McAuliffe 2014; McLeavey 1994; Morgan 1993; Morthorst 2012; Patsiokas 1985; Priebe 2012; Salkovskis 1990; Stewart 2009; Tapolaa 2010; Torhorst 1987; Torhorst 1988; Turner 2000; Tyrer 2003; Vaiva 2006; Van der Sande 1997a; Van Heeringen 1995; Waterhouse 1990; Wei 2013; Weinberg 2006; Welu 1977). In Brown 2005, most participants (85.0%) were diagnosed with more than one psychiatric disorder; however, the authors did not provide information on specific diagnoses. In an additional three trials (Carter 2005; McMain 2009; Slee 2008), the median number of psychiatric diagnoses was greater than two, suggesting that participants in these trials were also diagnosed with more than one psychiatric disorder; however, none of the three reported further information on specific diagnoses. In one trial, 45.0% of the participants were diagnosed with comorbid personality disorder and substance misuse (Davidson 2014), whilst in another, just under half of the sample (45.9%) had a comorbid personality diagnosis (Gratz 2014).

1.1 Repetition of SH

There was no evidence of a significant treatment effect for CBT‐based psychotherapy on repetition of SH by post‐intervention in McAuliffe 2014 (23/171 vs 27/142; OR 0.66, 95% CI 0.36 to 1.21; k = 1; N = 313; GRADE: low quality).

By the six‐month follow‐up assessment, however, on the basis of data from 12 trials there was evidence of a significant treatment effect for CBT‐based psychotherapy on repetition of SH (Analysis 1.1; OR 0.54, 95% CI 0.34 to 0.85; k = 12; N = 1317), with moderate quality of evidence (see summary of findings Table 1). Omitting Weinberg 2006, which included only participants diagnosed with borderline personality disorder, did not materially affect this result. There was, however, evidence of a significant difference by modality (Analysis 1.1; test for subgroup differences: Chi²= 7.32, degrees of freedom (df) = 1, P = 0.007, I² = 86.3%). Specifically, although individual CBT‐based psychotherapy was associated with a significant treatment effect on repetition of SH by the six‐month follow‐up assessment (OR 0.52, 95% CI 0.36 to 0.75; k = 11; N = 1083), a group‐based approach was not associated with a significant treatment effect for this outcome in one trial (OR 1.35, 95% CI 0.75 to 2.41; k = 1; N = 234; McAuliffe 2014).

There was also evidence of a significant treatment effect for CBT‐based psychotherapy by the 12‐month follow‐up assessment in 10 trials (Analysis 1.2; OR 0.80, 95% CI 0.65 to 0.98; k = 10; N = 2142), again with a moderate quality of evidence (see summary of findings Table 1). Once again, omitting Weinberg 2006 did not materially affect this result, nor did omitting Hatcher 2011, which used Zelen's design. Hatcher 2011 also reported numbers of participants self‐reporting an episode of SH rather than those admitted to hospital following an episode of SH. Using these data, however, did not materially affect this result. There was no evidence of a significant difference by modality for this outcome (Analysis 1.2; test for subgroup differences: Chi² = 1.68, df = 1, P = 0.19, I² = 40.6%).

In two trials data on repetition of SH from 12 to 24 months were reported. A significant treatment effect for this outcome was found (Analysis 1.3; OR 0.31, 95% CI 0.14 to 0.69; k = 2; N = 105; GRADE: moderate quality) (see summary of findings Table 1).

Including all 17 trials that reported information on repetition of SH suggested a significant treatment effect for CBT‐based psychotherapy by the final follow‐up assessment (i.e., including data for the last follow‐up assessment available in each trial) (Analysis 1.4; OR 0.70, 95% CI 0.55 to 0.88; k = 17; N = 2665). Excluding Hatcher 2011 or Weinberg 2006 did not materially affect these results. Once again, using data on self‐reported incidents of SH for Hatcher 2011 did not materially affect this result, nor did using data for the randomised rather than consenting group. There was also no evidence of a significant difference by modality for this outcome (Analysis 1.4; test for subgroup differences: Chi² = 3.08, df = 1, P = 0.08, I² = 67.5%). However, quality of evidence, as assessed by the GRADE criteria, was low for this outcome (see summary of findings Table 1).

With respect to frequency of SH, data from six trials indicated no significant treatment effect for CBT‐based psychotherapy on frequency of repetition of SH by final follow‐up (Analysis 1.5; k = 6; N = 594). Excluding Weinberg 2006 did not materially affect this result. There was no evidence of a significant difference by modality (Analysis 1.5; test for subgroup differences: Chi² = 1.17, df = 1, P = 0.28, I² = 14.2%). However, this outcome was associated with low quality of evidence (see summary of findings Table 1). One trial reported information on median, rather than mean, number of episodes of SH at six months. However, the authors found that although "[t]he rate of self‐harm episodes was lower in the [experimental] group. . . [it was not] significantly so" (Evans 1999b, p.22). A further trial reported information on median number of episodes of SH at 12 months' follow‐up, finding that "[t]he median number of self‐harm episodes was two in both [the experimental and TAU] groups" (Tyrer 2003, p. 972).

1.2 Treatment adherence

Data on adherence was reported for both the experimental and control groups in one trial in which a significant treatment effect for CBT‐based psychotherapy on the proportion of participants who completed all 12 sessions of therapy in addition to the three follow‐up appointments was found (40/40 vs 33/42; OR 22.97, 95% CI 1.29 to 409.37; k = 1; N = 82; Slee 2008).

Four trials reported adherence data for the experimental group only (Brown 2005; Evans 1999b; Husain 2014; McAuliffe 2014). Brown 2005 found that "participants in the cognitive therapy (CT) group participated in a mean (SD) of 8.92 (5.97) CT sessions (range 0‐24). Thirty participants (50%) received ten or more CT sessions" (p. 568). In Evans 1999b, five participants in the experimental group did not have specific sessions of manual‐assisted cognitive‐behaviour therapy (MACT) and received almost all input from the booklet component of CBT alone. Overall, 17 of the 18 participants in the experimental group received the booklets. Husain 2014 found that "more than half of the (intervention) group attended all six sessions (n = 56)" (p. 466).

McAuliffe 2014, in which a group‐based approach was used, likewise found that "almost half of those assigned to [problem‐solving therapy] (103, 46.4%) attended all 6 therapy sessions" (p. 4).

1.3 Depression

There was no evidence of a significant treatment effect for CBT‐based psychotherapy on depression scores at the post‐intervention assessment in McAuliffe 2014 (mean 18.20, SD 14.80, n = 171 vs mean 20.60, SD 16.0, n = 142; MD ‐2.40, 95% CI ‐5.84 to 1.04; k = 1; N = 313).

Data on depression scores at six months' follow‐up suggested a significant treatment effect for CBT‐based psychotherapy on depression scores (Analysis 1.6; SMD ‐0.30, 95% CI ‐0.50 to ‐0.10; k = 11; N = 1668). Omitting Hatcher 2011, which used Zelen's design, did not materially affect this result. There was also no evidence of a significant difference by modality (Analysis 1.6; test for subgroup differences: Chi² = 1.38, df = 1, P = 0.24, I² = 27.3%).

Seven trials reported data on depression scores at 12 months, suggesting evidence of a significant treatment effect for psychological therapy (Analysis 1.7; SMD ‐0.36, 95% CI ‐0.64 to ‐0.07; k = 7; N = 1130; I² = 76%). This outcome was associated with substantial levels of heterogeneity (I²= 76%). Omitting Hatcher 2011 did not materially affect the result nor the heterogeneity. Visual inspection of the forest plot did not clearly indicate which trial/s contributed to this substantial level of heterogeneity.

Only two trials reported depression scores between 12 and 24 months' follow‐up; however, there was no evidence of a significant treatment effect for CBT‐based psychotherapy (Analysis 1.8; k = 2; N = 225). One trial also reported data on depression scores at 6 and 12 months' follow‐up (Hawton 1987a); however, there was not enough information to enable calculation of the SD. Nevertheless, the authors reported that there were no significant differences between groups in BDI scores at any time point.

Analysis of all 14 trials at final follow‐up indicated a significant treatment effect for CBT‐based psychotherapy on depression (Analysis 1.9; SMD ‐0.31, 95% CI ‐0.48 to ‐0.14; k = 14; N = 1859). Omitting Hatcher 2011 did not materially affect this result.

1.4 Hopelessness

There was no evidence of a significant treatment effect for CBT‐based psychotherapy on hopelessness at the post‐intervention assessment in three trials, regardless of treatment modality (Analysis 1.10; test for subgroup differences: Chi² = 2.06, df = 1, P = 0.15, I² = 51.5%).

However, by the six‐month follow‐up assessment, CBT‐based psychotherapy was associated with a significant treatment effect in four trials (Analysis 1.11; SMD ‐0.36, 95% CI ‐0.58 to ‐0.13; k = 4; N = 968). There was evidence of a difference by treatment modality for this outcome, however (Analysis 1.11; test for subgroup differences: Chi² = 8.11, df = 1, P = 0.004, I² = 87.7%). A group‐based CBT‐based psychotherapy approach was not associated with a significant treatment effect on hopelessness scores at six months in one trial (MD ‐0.30, 95% CI ‐1.89 to 1.29; k = 1; N = 234; McAuliffe 2014).

Three trials reported data on hopelessness scores at 12 months, again showing evidence of a significant treatment effect for CBT‐based psychological therapy (Analysis 1.12; MD ‐1.89, 95% CI ‐2.97 to ‐0.81; k = 3; N = 539). Omitting Hatcher 2011, which used Zelen's design, did not materially affect these results.

Analyses of all seven trials also suggested evidence of a significant treatment effect at final follow‐up (Analysis 1.13, SMD ‐0.31, 95% CI ‐0.51 to ‐0.10; k = 7; N = 1017). Omitting Hatcher 2011 did not materially affect this result. There was also no evidence of a significant treatment difference by modality for this outcome (Analysis 1.13; test for subgroup differences: Chi² = 3.65, df = 1, P = 0.06, I² = 72.6%).

1.5 Suicidal ideation

There was no evidence of a significant treatment effect for CBT‐based psychotherapy in three trials at the post‐intervention assessment, regardless of treatment modality (Analysis 1.14; k = 3; N = 360; test for subgroup differences: Chi² = 1.84, df = 1, P = 0.17, I² = 45.8%). However, sensitivity analyses using the fixed‐effect, rather than random‐effects model, suggested evidence of a significant treatment effect for CBT‐based psychotherapy on this outcome (fixed: MD ‐1.93, 95% CI ‐3.83 to ‐0.04).

By the six‐month follow‐up assessment, CBT‐based psychotherapy was associated with a significant treatment effect for suicidal ideation scores (Analysis 1.15; SMD ‐0.32, 95% CI ‐0.51 to ‐0.13; k = 6; N = 1011). Omitting Hatcher 2011, which used Zelen's design, did not materially affect this result, nor did omitting Weinberg 2006, in which participants had been diagnosed with personality disorders. There was evidence of a significant difference by treatment modality, however (Analysis 1.15; test for subgroup differences: Chi² = 6.69, df = 1, P = 0.010, I² = 85.1%), with a group‐based CBT‐based psychotherapy approach not appearing to be associated with a significant treatment effect for this outcome (Analysis 1.15; MD ‐0.20, 95% CI ‐2.49 to 2.09; McAuliffe 2014).

Data from Hatcher 2011 suggested that CBT‐based psychotherapy was not associated with a significant treatment effect for suicidal ideation scores at 12 months (mean 3.70, SD 6.70, n = 187 vs mean 4.80, SD 7.40, n = 231; MD ‐1.10, 95% CI ‐2.45 to 0.25; k = 1; N = 418).

Including all eight trials suggested evidence for a significant treatment effect for psychological therapy on suicidal ideation scores at final follow‐up (Analysis 1.16; SMD ‐0.32, 95% CI ‐0.53 to ‐0.11; k = 8; N = 1129). Omitting Hatcher 2011 or Weinberg 2006 did not materially affect this result. However, once again there was evidence of a significant difference by treatment modality (Analysis 1.16; test for subgroup differences: Chi² = 4.61, df = 1, P = 0.03, I² = 78.3%), with a group‐based psychotherapy approach not associated with a significant treatment effect for this outcome (Analysis 1.16; MD ‐0.02, 95% CI ‐0.24 to 0.20; McAuliffe 2014).

Wei 2013 recorded data on the proportion of participants self‐reporting suicidal ideation. There was no evidence of a significant treatment effect for CBT‐based psychotherapy in this trial at the six‐month follow‐up assessment (30/35 vs 32/40; OR 1.50, 95% CI 0.44 to 5.10; k = 1; N = 75). Although data were also available for the 12‐month follow‐up period, authors reported a greater number of participants in the CBT arm who self‐reported suicidal ideation (n = 30) than were reported to have been followed‐up by this point (n = 25). As we were unable to clarify these numbers with the authors, we have excluded this analysis from the review.

1.6 Problem solving

Two trials recorded dichotomous data on problem‐solving as the proportion of participants reporting improvement in problems. There was evidence of a significant treatment effect for CBT‐based psychotherapy on problem‐solving in these trial trials at the six‐month follow‐up assessment (Analysis 1.17; OR 2.81, 95% CI 1.50 to 5.24; k = 2; N = 231). However, for the same dichotomous outcome, there was no indication of any apparent treatment effect at the 12‐month follow‐up assessment in Hawton 1987a (24/30 vs 26/35; OR 1.38, 95% CI 0.43 to 4.47; k = 1; N = 65). Gibbons 1978 reported data for problem‐solving at the 24‐month follow‐up assessment, with evidence of a significant treatment effect for CBT‐based psychotherapy (64/73 vs 40/73; OR 5.87, 95% CI 2.54 to 13.54; k = 1; N = 146). Analysis of both these trials at the final follow‐up assessment, however, suggested no overall evidence of a significant treatment effect for CBT‐based psychotherapy on problem‐solving (Analysis 1.18; k = 2; N = 211). On the other hand, there was a significant difference using the fixed‐effect model (fixed: OR 3.66, 95% CI 1.88 to 7.09).

Data on problem‐solving scores at post‐intervention indicated no evidence of a significant treatment effect for CBT‐based psychotherapy with no evidence of a significant difference by treatment modality (Analysis 1.19; test for subgroup differences: Chi² = 0.07, df = 1, P = 0.79, I² = 0%). By the six‐month follow‐up, however, there was evidence of a significant treatment effect for CBT‐based psychotherapy for this outcome (Analysis 1.20; SMD 0.33, 95% CI 0.08 to 0.58; k = 4; N = 949). Omitting Hatcher 2011, which used Zelen's design, caused this effect to become non‐significant (MD 0.24, 95% CI ‐0.03 to 0.51). There was also evidence of a significant difference by treatment modality (Analysis 1.20; test for subgroup differences: Chi² = 8.11, df = 1, P = 0.004, I² = 87.7%), with a single trial of group‐based psychotherapy indicating no evidence of a significant treatment effect for this outcome (MD 0.30, 95% CI ‐3.55 to 4.15; McAuliffe 2014). There was no apparent benefit for CBT‐based psychotherapy in a single trial at 12 months (mean 92.2, SD 18.1, n = 190 vs mean 90.5, SD 18.9, n = 233; MD 1.70, 95% CI ‐1.84 to 5.24; k = 1; N = 423; Hatcher 2011). Combining all five trials at final follow‐up suggested evidence of a significant treatment effect for problem solving at the final follow‐up assessment (Analysis 1.21; SMD 0.26, 95% CI 0.02 to 0.50; k = 5; N = 958). Omitting Hatcher 2011 caused the association to become non‐significant (SMD 0.35, 95% CI ‐0.00. to 0.69; k = 4; N = 535).

Finally, Salkovskis 1990 reported the severity of participants' three main problems using the Personal Questionnaire Rapid Scaling Technique (PQRST) at one week, one month, three months, six months and one year following entry to treatment. The authors reported that "the problem‐solving therapy group showed significantly better overall results on their three main problems when compared with the group who received 'treatment as usual' " (Salkovskis 1990, p. 873).

1.7 Suicide

Fifteen trials reported data on suicides during follow‐up; however, there was no evidence of a significant treatment effect for CBT‐based psychotherapy on suicides by final follow‐up (Analysis 1.22; k = 15; N = 2354). In Tyrer 2003, there was one death in the experimental group that medical staff considered to be a suicide, although the coroner did not record a suicide verdict in this case. Including this death as a suicide did not materially change the overall result.

2.1 Repetition of SH

Group‐based emotion‐regulation psychotherapy was associated with a significant treatment effect by the post‐intervention assessment (Analysis 2.1; OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83). Quality of evidence for this outcome, however, was low (see summary of findings Table 2).

With respect to frequency of repetition of SH, there was no evidence of a significant treatment effect for group‐based emotion‐regulation psychotherapy by the post‐intervention assessment (Analysis 2.1; k = 2; N = 83). Once again, this was associated with a low quality of evidence (see summary of findings Table 2).

2.2 Treatment adherence

No data available.

2.3 Depression

There was evidence of a significant treatment effect for group‐based emotion‐regulation therapy on depression scores at the post‐intervention assessment (Analysis 2.8; MD ‐9.59, 95% CI ‐13.43 to ‐5.75; k = 2; N = 83).

2.4 Hopelessness

No data available.

2.5 Suicidal ideation

No data available.

2.6 Problem solving

No data available.

2.7 Suicide

There were no suicides in either group for either trial.

2.8 Repetition of SH

There was a significant treatment effect for mentalisation‐based therapy by the conclusion of the 18‐month treatment period, with fewer participants in the experimental group engaging in SH based on data obtained by correspondence (Analysis 2.1; 18/71 vs 31/63; OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134). However, quality of evidence was moderate (see summary of findings Table 2).

There was also evidence of a significant treatment effect for mentalisation‐based therapy on frequency of SH episodes by the post‐intervention assessment according to data obtained by correspondence (Analysis 2.5; mean 0.38, SD 0.83, n = 71 vs mean 1.66, SD 2.87, n = 63; MD ‐1.28, 95% CI ‐2.01 to ‐0.55; k = 1; N = 134). Once again, quality of evidence was moderate (see summary of findings Table 2).

2.9 Treatment adherence

There was no evidence of a significant treatment effect for mentalisation‐based therapy on the proportion of participants who completed the full course of treatment (Analysis 2.7; k = 1; N = 134).

2.10 Depression

Mentalisation‐based therapy was associated with a significant treatment effect for depression at the post‐intervention assessment (Analysis 2.8; mean 14.80, SD 8.55, n = 71 vs mean 18.68, SD 8.76, n = 63; MD ‐3.88, 95% CI ‐6.82 to ‐0.94; k = 1; N = 134).

2.11 Hopelessness

No data available.

2.12 Suicidal ideation

No data available.

2.13 Problem solving

No data available.

2.14 Suicide

There had been no suicides in either treatment arm by the time of the post‐treatment assessment.

2.18 Hopelessness

No data available.

2.19 Suicidal ideation

There was also evidence of a significant treatment effect for suicidal ideation at the post‐treatment assessment (Analysis 2.11; mean 3.83, SD 8.03, n = 12 vs mean 11.58, SD 9.21, n = 12; MD ‐7.75, 95% CI ‐14.66 to ‐0.84; k = 1; N = 24).

2.20 Problem solving

No data available.

2.21 Suicide

No data available.

2.22 Repetition of SH

We obtained data on repetition of SH through correspondence for all three trials. There was no clear evidence of a significant treatment effect for DBT compared to TAU in terms of the proportion of patients repeating SH in three trials by the post‐intervention assessment (Analysis 2.1; k = 3; N = 267). Similarly, there was no evidence of a significant treatment effect for DBT by the 12‐month follow‐up assessment in two trials (Analysis 2.3; k = 2; N = 172). Combining data from all three trials by the final assessment period suggested no evidence of a significant treatment effect for DBT versus TAU (Analysis 2.4; k = 3; N = 247). Quality of evidence for these three outcomes was low, however (see summary of findings Table 2).

There was evidence of a significant treatment effect for DBT as compared to TAU on frequency of SH by the post‐intervention assessment (Analysis 2.5; MD ‐18.82, 95% CI ‐36.68 to ‐0.95; k = 3; N = 292). Once again quality of evidence for this outcome was low (see summary of findings Table 2).

Following a "naturalistic" follow‐up period, data from Linehan 1993a (N = 39) indicated that the effectiveness of DBT in the Linehan 1991 trial was maintained at 24 months; however, this outcome was only investigated for a proportion of the original participants (61.9%) who the researchers were able to contact at 24 months. Results have therefore not been reproduced in the present review.

2.23 Treatment adherence

There was no evidence of a significant treatment effect for DBT for the number of participants completing the full course of treatment in one trial (McMain 2009) (55/90 vs 56/90; OR 0.95, 95% CI 0.52 to 1.74; k = 1; N = 180). Numbers completing treatment in the control group for Priebe 2012 were not provided. Therefore we could not incorporate the results of this trial in a meta‐analysis.

Although Linehan 1991 did not provide numerical data on treatment adherence, the authors did report that participants allocated to the DBT group were ". . . significantly more likely to start individual therapy. . . (100% versus 73%)" (Linehan 1991, p. 1062).

2.24 Depression

There was no evidence of a significant treatment effect for DBT as compared to TAU on depression scores at the post‐intervention assessment (Analysis 2.8; k = 2; N = 198).

Data from McMain 2012 furthermore suggested there was no evidence of a significant treatment effect for DBT on depression at the 24‐month assessment (mean 22.24, SD 16.40, n = 90 vs mean 21.67, SD 14.82, n = 90; MD 0.57, 95% CI ‐4.00 to 5.14; k = 1; N = 180).

2.25 Hopelessness

We obtained data on hopelessness by correspondence for one trial (Linehan 1991). There was no evidence of a significant treatment effect for DBT at the 24‐month follow‐up assessment (mean 10.86, SD 6.04, n = 7 vs mean 10.69, SD 6.18, n = 11; MD 0.17, 95% CI ‐5.61 to 5.95; k = 1; N = 18).

2.26 Suicidal ideation

One trial reported data on suicidal ideation (Linehan 1991). Again, there was no significant treatment effect for DBT at the post‐intervention assessment (mean 24.01, SD 19.80, n = 46 vs mean 31.92, SD 26.80, n = 35; MD ‐7.91, SD ‐18.47 to 2.65; k = 1; N = 81).

2.27 Problem solving

No data available.

2.28 Suicide

Although a suicide occurred in the DBT arm of Linehan 1991 before the post‐intervention assessment, there were no suicides in Priebe 2012 or in McMain 2009. There was therefore no evidence of a significant treatment effect for this outcome (Analysis 2.13; k = 3; N = 317). There were no suicides in Priebe 2012 or in McMain 2009 by the 24‐month follow‐up assessment.

2.29 Repetition of SH

There was no evidence of a treatment effect for DBT versus treatment by expert on repetition of SH by either the post‐intervention assessment (Analysis 2.1; k = 1; N = 97) or by the 12‐month follow‐up period (Analysis 2.3; k = 1; N = 97). Quality of evidence for this outcome at both time points, as assessed by the GRADE criteria, was very low (see summary of findings Table 2).

Study authors did, however, state that those allocated to the DBT group had " . . . half the rate of suicide attempts compared with the CTB‐E group (23.1% vs 46%. . . hazard ratio, 2.66, P = 0.005)" (Linehan 2006, p. 761). Nevertheless, correspondence with authors regarding the total number of parasuicidal acts across the 12‐month follow‐up period revealed no evidence of a significant treatment effect for DBT (mean 8.79, SD 10.81, n = 52 vs mean 23.64, SD 77.34, n = 45; MD ‐14.85, 95% CI ‐37.64 to 7.94; k = 1; N = 97). Quality of evidence for this outcome was also very low (see summary of findings Table 2).

2.30 Treatment adherence

No data available.

2.31 Depression

There was no evidence of a significant treatment effect on depression scores either at the post‐intervention assessment (Analysis 2.8; k = 1; N = 89) or at the 12‐month follow‐up assessment (Analysis 2.10; k = 1 ; N = 81) in this trial.

2.32 Hopelessness

No data available.

2.33 Suicidal ideation

There was also no evidence of a significant treatment effect for DBT for suicidal ideation scores at either the post‐intervention (Analysis 2.11; k = 1; N = 89) or 12‐month follow‐up assessments (Analysis 2.12; k = 1; N = 81).

2.34 Problem solving

No data available.

2.35 Suicide

There were no suicides in either treatment arm by the end of the 12‐month follow‐up period.

2.36 Repetition of SH

Data obtained by correspondence suggested there was no evidence of a significant treatment effect for the DBT prolonged protocol on repetition of SH either by the post‐treatment assessment (Analysis 2.1; k = 1; N = 18) or by the three‐month follow‐up (Analysis 2.2; k = 1; N = 18). Quality of evidence for both these time points was low, however (see summary of findings Table 2).

Data on frequency of SH, obtained following correspondence with authors, also suggested no apparent benefit of the DBT prolonged exposure protocol by either the post‐treatment (Analysis 2.5; k = 1; N = 18) or three‐month follow‐up (Analysis 2.6; k = 1; N = 18) assessments. Quality of evidence, as assessed by the GRADE criteria, was low (see summary of findings Table 2). Data on frequency of suicide re‐attempts could not be analysed as there were no repeat suicide attempts in the control group by the final three‐month follow‐up assessment.

2.37 Treatment adherence

There was no significant difference between the experimental and control groups regarding the number of participants who attended the full one‐year course of treatment (Analysis 2.7; k = 1; N = 26). According to the authors, ". . . one therapist. . . was not adherent to DBT and had a 100% dropout rate" (p. 12). Excluding the four participants treated by this therapist did not, however, materially affect this result.

2.38 Depression

There was no evidence of a significant treatment effect for the DBT prolonged exposure protocol for depression scores at either the post‐treatment (Analysis 2.8; k = 1; N = 18) or three‐month follow‐up (Analysis 2.9; k = 1; N = 18) assessments.

2.39 Hopelessness

No data available.

2.40 Suicidal ideation

No data available.

2.41 Problem solving

No data available.

2.42 Suicide

There was no evidence of a significant treatment effect on death by suicide by the three‐month follow‐up assessment (Analysis 2.14: 0/17 vs 1/9; OR 0.16, 95% CI 0.01 to 4.41; k = 1; N = 26) in this trial.

3.1 Repetition of SH

There was no evidence of a significant treatment effect for case management on repetition of SH by the post‐intervention assessment (Analysis 3.1; k = 4; N = 1608). Supplementing hospital‐recorded episodes of SH with self‐reported data for Morthorst 2012 did not materially affect this result. There was also no indication of a significant difference by comparator condition (i.e., TAU vs EUC) for this outcome (Analysis 3.1; test for subgroup differences: Chi² = 0.20, df = 1, P = 0.66, I² = 0%). Quality, as assessed using the GRADE criteria, was moderate for this outcome (see summary of findings Table 3).

One trial disaggregated data on repetition of SH by sex (Hvid 2011). Although there was no evidence of a significant treatment effect for males in this trial (4/20 vs 4/18; OR 0.88, 95% CI 0.18 to 4.17; k = 1; N = 38), case management was associated with a significant reduction in repetition of SH in females (2/49 vs 10/46; OR 0.15, 95% CI 0.03 to 0.74; k = 1; N = 95).

Multiple readmissions for SH were, however, significantly more common in the case management group than in the control group over the treatment period in one trial (Clarke 2002: 9/220 vs 2/247; OR 5.23, 95% CI 1.12 to 24.45; k = 1; N = 467). Quality of evidence for this outcome was moderate (see summary of findings Table 3).

3.2 Treatment adherence

The authors of one trial reported that "11 participants in the assertive case management group did not receive the intervention" (Kawanishi 2014, p. 197). However, as corresponding numbers for the enhanced usual care group were not reported, we were unable to analyse the effect of assertive case management on treatment adherence for this trial.

3.3 Depression

No data available.

3.4 Hopelessness

Although the Beck Hopelessness Scale was administered to participants throughout the follow‐up period in one trial (Kawanishi 2014), the authors did not report data on this outcome. Correspondence, however, revealed that they are currently analysing these data and will present them in a future report.

3.5 Suicidal ideation

No data available.

3.6 Problem solving

No data available.

3.7 Suicide

There was no evidence of a significant treatment effect on suicide by the post‐intervention assessment (Analysis 3.2; k = 4; N = 1757), nor was there evidence of a significant difference by comparator condition (i.e., TAU vs EUC) for this outcome (Analysis 3.2; test for subgroup differences: Chi² = 0.67, df = 1, P = 0.41, I² = 0%).

4.1 Repetition of SH

There was no evidence of a significant treatment effect on repetition of SH by the 12‐month follow‐up assessment, although the difference in repetition between groups was fairly marked (Analysis 4.1; k = 1; N = 391). Quality of evidence for this outcome, as assessed by the GRADE criteria, was low (see summary of findings Table 4).

4.2 Treatment adherence

There was, however, a significant treatment effect for adherence with outpatient aftercare appointments in this trial (129/252 vs 102/256; OR 1.58, 95% CI 1.11 to 2.25; k = 1; N = 508).

4.3 Depression

No data available.

4.4 Hopelessness

No data available.

4.5 Suicidal ideation

No data available.

4.6 Problem solving

No data available.

4.7 Suicide

There was no evidence of a significant treatment effect for the number of participants who died by suicide over the 12‐month follow‐up period (Analysis 4.3; k = 1; N = 391) in this trial.

4.8 Repetition of SH

There was no evidence of a significant treatment effect for receiving continued therapeutic contact with the original hospital therapist on repetition of SH by the 12‐month follow‐up assessment (Analysis 4.1; k = 1; N = 136). A very low quality of evidence was associated with this outcome (see summary of findings Table 4).

4.9 Treatment adherence

There was evidence of a significant treatment effect for treatment adherence, favouring the same‐therapist group (49/68 vs 36/73; OR 2.65, 95% CI 1.32 to 5.34; k = 1; N = 141).

4.10 Depression

Depression scores did not differ significantly between groups at the 12‐month follow‐up assessment (Analysis 4.2: mean 6.20, SD 6.90, n = 65 vs mean 7.60, SD 9.20, n = 62; MD ‐1.40, 95% CI ‐4.24 to 1.44; k = 1; N = 127).

4.11 Hopelessness

No data available.

4.12 Suicidal ideation

No data available.

4.13 Problem solving

No data available.

4.14 Suicide

There was no evidence of a significant treatment effect for receiving continued therapeutic contact with the original hospital therapist on suicide by the 12‐month follow‐up assessment (Analysis 4.3; k = 1; N = 136).

5.1 Repetition of SH

There was no evidence of a significant treatment effect for this package of interventions in terms of hospital‐recorded episodes of SH by 12‐month post‐intervention assessment (66/327 vs 73/357; OR 0.98, 95% CI 0.68 to 1.43; k = 1; N = 684). This outcome had a low quality of evidence (see summary of findings Table 5). Using data from the randomised (including both patients who, following treatment allocation, subsequently consented to participation and those who did not), rather than consenting, sample did not materially affect these results.

Investigators also presented data on repetition of SH by repeater status at trial entry. However, there was no evidence of a significant treatment effect for those with no history of SH prior to the index attempt compared to those with a history of multiple SH episodes by the post‐intervention assessment (those with a history of multiple episodes of SH: 47/176 vs 56/194; OR 0.90, 95% CI 0.57 to 1.42; k = 1; N = 370; those without a history of multiple episodes of SH: 19/151 vs 17/163; OR 1.24, 95% CI 0.62 to 2.48; k = 1; N = 314).

With respect to frequency of SH, the authors reported that "[a]lthough there were 20% fewer episodes in the intervention group, the difference was not statistically significant" (Hatcher 2015, p. 17).

5.2 Treatment adherence

No data available.

5.3 Depression

There was no significant treatment effect for this intervention on depression scores at the 12‐month post‐intervention assessment (mean 6.8, SD 4.9, n = 211 vs mean 6.5, SD 5.1, n = 234; MD 0.30, 95% CI ‐0.63 to 1.23; k = 1; N = 445).

5.4 Hopelessness

There was also no apparent treatment effect for this intervention on hopelessness scores at the 12‐month post‐intervention assessment (mean 8.3, SD 6.3, n = 210 vs mean 8.4, SD 6.4, n = 233; MD ‐0.10, 95% CI ‐1.28 to 1.08; k = 1; N = 443).

5.5 Suicidal ideation

No data available.

5.6 Problem solving

No data available.

5.7 Suicide

Correspondence with authors revealed there was no significant treatment effect for this intervention package on suicides by the 12‐month post‐intervention assessment (1/327 vs 2/357; OR 0.54, 95% CI 0.05 to 6.03; k = 1; N = 684). One death in the experimental and one in the control group were due to uncertain causes as they had yet to be investigated by the Coroner. However, assuming these deaths were attributable to suicide did not materially affect this result.

5.8 Repetition of SH

There was no evidence of a significant treatment effect for this intervention on re‐presentation to hospital following an episode of SH by the time of the post‐intervention assessment (34/95 vs 29/72; OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167). Using data from the randomised sample only (including both patients who, following treatment allocation, subsequently consented to participation and those who did not) did not materially affect these results. Both outcomes had a low quality of evidence, as assessed using the GRADE criteria (see summary of findings Table 5).

Investigators presented information on repetition of SH by repeater status; however, there was no significant difference in repetition of SH between groups for either those with a history of multiple episodes of SH (24/60 vs 21/40; OR 0.60, 95% CI 0.27 to 1.35; k = 1; N = 100) or for those without a history of multiple episodes of SH (10/35 vs 8/32; OR 1.20, 95% CI 0.41 to 3.55; k = 1; N = 67).

5.9 Treatment adherence

No data available.

5.10 Depression

There was no treatment effect for this intervention on depression scores at the 12‐month post‐intervention assessment (mean 5.80, SD 4.50, n = 66 vs mean 6.30, SD 4.30, n = 48; MD ‐0.50, 95% CI ‐2.13 to 1.13; k = 1; N = 114).

5.10 Hopelessness

There was also no apparent treatment effect for this intervention on hopelessness scores at the post‐intervention assessment (mean 5.00, SD 4.40, n = 66 vs mean 5.70, SD 4.80, n = 47; MD ‐0.70, 95% CI ‐2.43 to 1.03; k = 1; N = 113).

However, the authors note that "whilst there was a greater change in [hopelessness] scores at . . . 12 months [i.e., the post‐intervention assessment] in the intervention group, the group had a significantly lower baseline score . . . because of the significant differences in baseline scores and missing follow up data we. . . used a mixed linear model to estimate the differences in scores at [the post‐intervention assessment]." Using this model the authors found "there was a decrease in [h]opelessness scores in the treatment group compared to the usual care group but this was statistically non‐significant" (Hatcher 2016a, ePub version, p. 5).

5.11 Suicide ideation

No data available.

5.12 Problem solving

No data available.

5.13 Suicide

Correspondence with authors revealed there was no significant treatment effect for this intervention on suicides by the time of the post‐intervention assessment (0/72 vs 1/95; OR 0.43, 95% CI 0.02 to 10.82; k = 1; N = 167).

6.1 Repetition of SH

Due to the definition of SH used in the report for one trial of postcards, we obtained data for this trial on repetition of SH through correspondence (Hassanian‐Moghaddam 2011).

Overall, there was no evidence of a significant treatment effect on the proportion of patients repeating SH by the post‐intervention assessment (Analysis 5.1; k = 4; N = 3277). Excluding Carter 2005, which used Zelen's design, did not materially affect this result. Quality of evidence, as assessed using the GRADE criteria, was very low for this outcome (see summary of findings Table 6). Visual examination of the forest plot suggested that the result for Kapur 2013a may have been an outlier. Removing this trial reduced heterogeneity to 0% and suggested a significant treatment effect for postcards on repetition of SH (OR 0.78, 95% CI 0.62 to 0.97; k = 3; N = 3212).

There was no evidence of a significant treatment effect for postcards on repetition of SH by the 12‐month follow‐up assessment in two trials (Analysis 5.2; k = 2; N = 2885). The quality of evidence for this outcome was moderate (see summary of findings Table 6). Excluding Carter 2005, however, caused this result to become significant (OR 0.67, 95% CI 0.52 to 0.86; k = 1; N = 2113) as did a sensitivity analysis using the fixed‐effect rather than random‐effects model (fixed: OR 0.75, 95% CI 0.61 to 0.91).

Combining data from both time points indicated no overall significant effect for postcards by the final follow‐up assessment (Analysis 5.3; k = 4; N = 3277). Excluding Carter 2005 did not materially affect this result. However, as before, excluding Kapur 2013a caused this result to become significant (OR 0.77, 95% CI 0.63 to 0.95) as did a sensitivity analysis using the fixed‐effect model (fixed: OR 0.79, 95% CI 0.66 to 0.95), quality of evidence was again very low for this outcome (see summary of findings Table 6).

Data on repetition of SH by the post‐intervention assessment and 12‐month follow‐up were available by sex in one trial (Carter 2005; Carter 2007); however, there was no evidence of a significant treatment effect for postcards in either sex by either time point (post‐intervention: males 20/145 vs 16/102; OR 0.86, 95% CI 0.42 to 1.75; k = 1; N = 247 versus females 37/233 vs 51/291; OR 0.89, 95% CI 0.56 to 1.41; k = 1; N = 524; 12 months' follow‐up: males 26/145 vs 19/102; OR 0.95, 95% CI 0.50; k = 1; N = 247 versus females 54/233 vs 59/291; OR 1.19, 95% CI 0.78 to 1.80; k = 1; N = 524).

With respect to frequency of SH, we obtained data on mean number of repeat SH episodes by correspondence for three of the four trials of postcards (Carter 2005; Hassanian‐Moghaddam 2011; Kapur 2013a). For the one remaining trial (Beautrais 2010), the available data indicated a reduced mean number of SH episodes for the experimental group (0.57 vs 0.78); however, as no information on SDs, t‐test or F statistics were reported, we were unable to impute SDs using the method outlined in Townsend 2001 to calculate the mean difference in frequency of SH episodes between groups. Overall, there was no evidence of a significant treatment effect for postcards on frequency of repetition of SH by the post‐intervention assessment (Analysis 5.4; k = 3; N = 1,097). Quality of evidence for this outcome was very low (see summary of findings Table 6).

By the 12‐month follow‐up assessment, there was similarly no evidence of a significant treatment effect for postcards in two trials (Analysis 5.5; k = 2; N = 984). One trial also provided data for the 24‐month follow‐up period; however, no evidence of a significant treatment effect was apparent (mean 0.21, SD 0.75, n = 217 vs mean 0.24, SD 0.68, n = 255; MD ‐0.03, 95% CI ‐0.16 to 0.10; k = 1; N = 472; Hassanian‐Moghaddam 2011). Quality of evidence was very low to moderate for these outcomes (see summary of findings Table 6).

Through correspondence, we were also able to obtain post hoc data on frequency of repetition of SH by the post‐intervention assessment by both sex and repeater status for three trials (Carter 2005; Hassanian‐Moghaddam 2011; Kapur 2013a). There was no evidence of a significant treatment effect for postcards on frequency of repetition by the post‐intervention assessment for either sex (males: Analysis 5.4; k = 3; N = 401; females: Analysis 5.4; k = 3; N = 695), those with a history of multiple episodes of SH (Analysis 5.4; k = 3; N = 339), or those without a history of multiple episodes of SH (Analysis 5.4; k = 3; N = 758). There was also no evidence of a significant treatment effect for postcards on frequency of repetition for males (Analysis 5.5; k = 2; N = 336), females (Analysis 5.5; k = 2; N = 647), those with a history of multiple episodes of SH (Analysis 5.5; k = 2; N = 296), or those without a history of multiple episodes of SH (Analysis 5.5; k = 2; N = 688) by the 12‐month follow‐up assessment in two trials. Correspondence with study authors revealed no significant treatment effect for postcards on frequency of repetition in either males (mean 0.33, SD 1.07, n = 116 vs mean 0.29, SD 0.82, n = 104; MD 0.04, 95% CI ‐0.21 to 0.29; k = 1; N = 220), females (mean 0.14, SD 0.52, n = 101 vs mean 0.21, SD 0.59, n = 151; MD ‐0.07, 95% CI ‐0.21 to 0.07, k = 1; N = 252), those with a history of multiple episodes of SH (mean 0.42, SD 1.06, n = 155 vs mean 0.51, SD 0.96, n = 183; MD ‐0.09, 95% CI ‐0.31 to 0.13; k = 1; N = 338), or those without a history of multiple episodes of SH (mean 0.09, SD 0.47, n = 62 vs mean 0.10, SD 0.41, n = 72; MD ‐0.01, 95% CI ‐0.16 to 0.14; k = 1; N = 134) by the 24‐month follow‐up assessment in one of these trials (Hassanian‐Moghaddam 2011).

6.2 Treatment adherence

No data available.

6.3 Depression

No data available.

6.4 Hopelessness

No data available.

6.5 Suicidal ideation

One trial recorded information on suicidal ideation at both the post‐intervention assessment and 12‐months' follow‐up (Hassanian‐Moghaddam 2011; Hassanian‐Moghaddam 2015). There was a significant treatment effect for the number of people reporting suicidal ideation at the post‐intervention assessment (302/1043 vs 446/1070; OR 0.57, 95% CI 0.48 to 0.68; k = 1; N = 2113). Data reported by the trial authors in a subsequent follow‐up paper suggested that this effect was maintained at the 12‐month follow‐up assessment (465/997 vs 588/1004; OR 0.62, 95% CI 0.52 to 0.74; k = 1; N = 2001; Hassanian‐Moghaddam 2015).

6.6 Problem solving

No data available.

6.7 Suicide

There was no evidence of a significant treatment effect for postcards on suicide by the post‐intervention assessment (Analysis 5.6; k = 4; N = 3464). Excluding Carter 2005, however, suggested a harmful effect of postcards on suicides (OR 3.74, 95% CI 1.04 to 13.51; k = 3; N = 2692).

Data on suicides by the 12‐month follow‐up assessment were available for one trial (i.e., Carter 2005); however, no significant treatment effect was found (Analysis 5.7; k = 1; N = 772).

6.8 Repetition of SH

There was no evidence of a significant treatment effect for emergency cards on repetition of SH by the post‐intervention assessment (Analysis 5.1; k = 2; N = 1039). Quality of evidence for this outcome was low (see summary of findings Table 6). There was also no evidence of a significant treatment effect for emergency cards by the time of the 12‐month follow‐up assessment in Evans 1999a (Analysis 5.2; k = 1; N = 827). For this outcome, quality of evidence as assessed by the GRADE criteria was moderate (see summary of findings Table 6).

Evans 1999a disaggregated data on repetition of SH by repeater status (i.e., those without a history of multiple episodes of SH versus those with a history of multiple episodes of SH) in post hoc analyses. Whilst there was no evidence of a significant treatment effect for emergency cards on repetition of SH in those without a history of multiple episodes of SH (18/221 vs 25/206; OR 0.64, 95% CI 0.34 to 1.22; k = 1; N = 427), emergency cards were associated with a significantly increased risk of repetition of SH in those with a history of multiple episodes of SH (52/194 vs 33/200; OR 1.85, 95% CI 1.14 to 3.03; k = 1; N = 394) in this trial.

Evans 1999a also reported data on frequency of repetition of SH as the proportion with no episodes at follow‐up, the proportion with a single episode at follow‐up, and the proportion of two or more repeat episodes of SH by the 12‐month follow‐up assessment. There was no significant difference between groups in the number of participants who had none (347/417 vs 351/410; OR 0.83, 95% CI 0.57 to 1.21; k = 1; N = 827), one (46/417 vs 32/410; OR 1.46, 95% CI 0.91 to 2.35; k = 1; N = 827), or two or more (24/417 vs 27/410; OR 0.87, 95% CI 0.49 to 1.53; k = 1; N = 827) episodes of SH over the six‐month follow‐up period.

This authors also presented data on frequency of repetition of SH by repeater status in post hoc analyses. For those without a history of multiple episodes of SH, there was no significant difference between groups in the number of participants who had none (203/221 vs 181/206; OR 1.56, 95% CI 0.82 to 2.95; k = 1; N = 427), one (13/221 vs 16/206; OR 0.74, 95% CI 0.35 to 1.58; k = 1; N = 427), or two or more (5/221 vs 9/206; OR 0.51, 95% CI 0.17 to 1.54; k = 1; N = 427) repeat episodes of SH. For those with a history of multiple episodes of SH, however, receipt of an emergency card was associated with a significant reduction in the number of participants with no further episodes of SH (142/194 vs 167/200; OR 0.54, 95% CI 0.33 to 0.88; k = 1; N = 394) coupled with a significant increase in the number of participants with one repeat episode of SH (33/194 vs 15/200; OR 2.53, 95% CI 1.33 to 4.82; k = 1; N = 394). There was no significant difference between the experimental and control groups with respect to the number of participants with or two or more subsequent episodes of SH for those with a history of multiple episodes of SH, however (19/194 vs 18/200; OR 1.10, 95% CI 0.56 to 2.16; k = 1; N = 394).

6.9 Treatment adherence

No data available.

6.10 Depression

No data available.

6.11 Hopelessness

No data available.

6.12 Suicidal ideation

No data available.

6.13 Problem solving

No data available.

6.14 Suicide

Data on suicides were reported in only one trial (Evans 1999a). There was no evidence of a significant treatment effect for emergency cards on suicide by the time of the six‐month follow‐up assessment (2/417 vs 1/410; OR 1.97, 95% CI 0.18 to 21.82; k = 1; N = 827).

6.15 Repetition of SH

There was no evidence of a significant treatment effect for a letter from patients' general practitioners on repetition of SH by the 12‐month follow‐up assessment (211/964 vs 189/968; OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932). A moderate quality of evidence was associated with this outcome (see summary of findings Table 6).

A post hoc analysis by sex, however, suggested that whilst there was no significant treatment effect for males (82/383 vs 84/413; OR 1.07, 95% CI 0.76 to 1.50; k = 1; N = 796), a GP letter was associated with a significant treatment effect on repetition of SH for females (30/581 vs 105/555; OR 0.23, 95% CI 0.15 to 0.36; k = 1; N = 1136).

In a second post hoc analysis, the authors also analysed repetition of SH by repeater status at trial entry and concluded that "[t]he odds ratio for the effect of the intervention in patients with a history of self‐harm was 0.57 (0.33 to 0.98), indicating a beneficial effect, and in those with no history was 1.32 (1.02 to 1.70), indicating a harmful effect" (Bennewith 2002, p. 1258). As the raw data on which these sub‐group results were based is not reported, we were unable to reproduce these results in this review.

6.16 Treatment adherence

There was no significant treatment effect for the number of participants with at least one contact with treatment services by the time of the 12‐month follow‐up assessment (351/599 vs 387/681; OR 1.08, 95% CI 0.86 to 1.34; k = 1; N = 1280).

6.17 Depression

No data available.

6.18 Hopelessness

No data available.

6.19 Suicidal ideation

No data available.

6.20 Problem solving

No data available.

6.21 Suicide

No data available.

6.22 Repetition of SH

There was no evidence of a significant treatment effect for telephone contact on repetition of SH at the six‐month follow‐up assessment in Wei 2013 (1/41 vs 4/40; OR 0.23, 95% CI 0.02 to 2.11; k = 1; N = 81), by the 12‐month follow‐up period in Cedereke 2002(14/83 vs 15/89; OR 1.00, 95% CI 0.45 to 2.23; k = 1; N = 172), or by the 24‐month follow‐up period in Vaiva 2006 (44/293 vs 59/312; OR 0.76, 95% CI 0.49 to 1.16; k = 1; N = 605). Combining data for these three time points indicated no significant treatment effect for telephone contact by the final follow‐up point (Analysis 5.3; k = 3; N = 840). Quality of evidence for these three time points was very low to low (see summary of findings Table 6).

With respect to frequency of repetition of SH, the mean number of episodes of SH was similar between treatment groups in both Cedereke 2002 (0.31 vs 0.30) and Vaiva 2006 (0.15 vs 0.19). However, as study authors did not report information on SDs, t‐test or F statistics, we were unable to impute SDs using the method outlined in Townsend 2001 to calculate the mean difference in the number of repeat episodes of SH between groups in these two trials.

6.23 Treatment adherence

There was no evidence of a significant treatment effect on the number of patients attending treatment at least once by 12‐month follow‐up assessment in one trial (60/83 vs 58/89, OR 1.39, 95% CI 0.73 to 2.67; k = 1; N = 172; Cedereke 2002).

6.24 Depression

There was no evidence of a significant treatment effect for telephone contact on depression at either the six‐month (mean 6.01, SD 8.87, n = 41 vs mean 5.85, SD 8.16, n = 40; MD 0.16, 95% CI ‐3.55 to 3.87; k = 1; N = 81) or the 12‐month (mean 5.73, SD 8.71, n = 36 vs mean 5.84, SD 8.23, n = 27; MD ‐0.11, 95% CI ‐4.32 to 4.10; k = 1; N = 63) follow‐up assessments in the only trial of telephone contact to report data on depression scores (Wei 2013).

6.25 Hopelessness

No data available.

6.26 Suicidal ideation

Suicidal ideation was recorded continuously in Cedereke 2002, whereas Wei 2013 recorded data on suicidal ideation dichotomously as the proportion self‐reporting an episode of suicidal ideation.

In Cedereke 2002, telephone contact was not associated with a significant treatment effect on suicidal ideation scores by the 12‐month follow‐up assessment (mean 5.80, SD 7.80, N = 5 vs mean 4.00, SD 6.20, N = 8; MD 1.80, 95% CI ‐6.27 to 9.87; k = 1; N = 13).

Telephone contact was also not associated with a significant treatment effect on the proportion of participants reporting suicidal ideation by the six‐month follow‐up assessment in Wei 2013 (26/41 vs 24/40; OR 1.16, 95% CI 0.47 to 2.83; k = 1; N = 81). By the 12‐month follow‐up assessment, however, telephone contact was associated with a significant treatment effect on the proportion of participants reporting suicidal ideation in this trial (24/36 vs 25/27; OR 0.16, 95% CI 0.03 to 0.79; k = 1; N = 63).

6.27 Problem solving

No data available.

6.28 Suicide

There was no evidence of a significant treatment effect for telephone contact on suicides by either the 12‐month (1/107 vs 1/109; OR 1.02, 95% CI 0.06 to 16.50; k = 1; N = 216; Cedereke 2002) or 24‐month (1/293 vs 2/312; OR 0.52, 95% CI 0.05 to 5.89; k = 1; N = 605; Vaiva 2006) follow‐up assessments. Combining data from these trials suggested no evidence of a significant treatment effect by the time of the final follow‐up assessment (Analysis 5.8; k = 2; N = 821).

6.29 Repetition of SH

Data obtained by correspondence from the authors indicated there were no repeat episodes of SH in either the treatment or control groups by the post‐intervention assessment. It was therefore not possible to calculate the pooled odds ratio and accompanying 95% confidence interval owing to zero cell counts (Analysis 5.1; k = 1; N = 68). A low quality of evidence was apparent for this outcome (see summary of findings Table 6).

6.30 Treatment adherence

No data available.

6.31 Depression

There was evidence of a significant treatment effect for mobile telephone‐based psychotherapy for depression at the post‐intervention assessment (mean 7.00, SD 5.00, n = 34 vs mean 14.60, SD 10.40, n = 34; MD ‐7.60, 95% CI ‐11.48 to ‐3.72; k = 1; N = 68).

However, a priori analyses suggested that this effect varied by sex. Mobile telephone‐based psychotherapy was associated with a significant treatment effect for depression at the post‐intervention assessment in males (mean 5.90, SD 2.40, n = 17 vs mean 13.30, SD 6.10, n = 17; MD ‐7.40, 95% CI ‐10.52 to ‐4.28; k = 1; N = 34) but not in females (mean 8.10, SD 6.30, n = 17 vs mean 11.60, SD 6.50, n = 17; MD ‐3.50, 95% CI ‐7.80 to 0.80; k = 1; N = 34).

6.32 Hopelessness

No data available.

6.34 Suicidal ideation

There was evidence of a significant treatment effect for mobile telephone‐based psychotherapy for suicidal ideation at the post‐intervention assessment (mean 3.60, SD 1.60, n = 34 vs mean 7.30, SD 5.50, n = 34; MD ‐3.70, 95% CI ‐5.63 to ‐1.77; k = 1; N = 68) in this trial.

When we analysed results separately by sex, however, there was no evidence of a significant treatment effect for mobile telephone‐based psychotherapy for suicidal ideation at the post‐intervention assessment in males (mean 3.50, SD 1.80, n = 17 vs mean 6.20, SD 5.50, n = 17; MD ‐2.70, 95% CI ‐5.45 to 0.05; k = 1; N = 34). There was, however, a significant treatment effect for females (mean 3.80, SD 1.40, n = 17 vs mean 8.90, SD 6.20, n = 17; MD ‐5.10, 95% CI ‐8.12 to ‐2.08; k = 1; N = 34).

6.35 Problem solving

No data available.

6.36 Suicide

Information obtained by correspondence indicated that there was one suicide in the experimental group by the time of the post‐intervention assessment and none in the control group. Mobile telephone‐based psychotherapy was not associated with a significant treatment effect for suicide by this time point (Analysis 5.6; k = 1; N = 68).

7.1 Repetition of SH

There was no evidence of a significant treatment effect for repetition of SH, defined as a 'self‐poisoning act', within the 12‐month follow‐up period (2/17 vs 4/16; OR 0.40, 95% CI 0.06 to 2.57; k = 1; N = 33) in this trial. A very low quality of evidence was associated with this outcome (see summary of findings Table 7).

7.2 Treatment adherence

There was no evidence of a significant treatment effect on the number of participants who completed the full course of treatment (2/19 vs 3/20; OR = 0.67, 95% CI 0.10 to 4.51; k = 1; N = 39).There was, however, evidence for a significant treatment effect in terms of the number of treatment sessions attended (mean 5.30, SD 0.48, n = 17 vs mean 4.20, SD 1.32, n = 16; MD 1.10, 95% CI 0.41 to 1.79; k = 1; N = 33).

7.3 Depression

No data available.

7.4 Hopelessness

There was no evidence of a significant treatment effect for hopelessness at the six‐month follow‐up assessment (mean 6.12, SD 4.61, n = 19 vs mean 4.35, SD 4.39, n = 20; MD 1.77, 95% CI ‐1.06 to 4.60; k = 1; N = 39).

7.5 Suicidal ideation

No data available.

7.6 Problem solving

Analysis of means estimated by the review authors from graphics in the original report suggests that, at the post‐intervention assessment, participants allocated to the experimental group had scores within the normal range whilst those allocated to the control group remained impaired according to both the Means‐Ends Problem‐Solving Scale (estimated means 6.4 vs 2.9) and the Self‐Rated Problem Solving Scale (estimated means 89.8 vs 78.0). Additionally, participants in the experimental group reported feeling more confident in solving problems post‐treatment according to scores on the Perceived Ability to Solve Current Problems scale (estimated means 0.9 vs 1.9). Lastly, both groups reported a reduction in self‐reported number of problems (estimated means 1.1 vs 1.5).

Results reported by the trial authors suggest an equal benefit of both treatments in reducing the "number of presenting problems. . ." (McLeavey 1994, p. 382). However, the authors conclude that IPSST was "significantly more effective . . . as determined by other outcome measures. . ." including measures of interpersonal cognitive problem‐solving, self‐rated personal problem‐solving ability, and perceived ability to cope with ongoing problems (McLeavey 1994, p.382).

7.7 Suicide

There were no suicides in either group during the 12‐month follow‐up period.

7.8 Repetition of SH

There was no evidence of a significant treatment effect with regards to the number of patients repeating SH by the 24‐month follow‐up period (2/12 vs 3/12; OR 0.60, 95% CI 0.08 to 4.45; k = 1; N = 24). This outcome was associated with a low quality of evidence (see summary of findings Table 7)

7.9 Treatment adherence

No data available.

7.10 Depression

Depression was measured using both the BDI and the ZSRDS in this trial. There was evidence of a significant treatment effect for behaviour therapy at the post‐treatment assessment according to both measures (BDI: mean 4.00, SD 4.00, n = 12 vs mean 14.00, SD 12.00, n = 12; MD ‐10.00, 95% CI ‐17.16 to ‐2.84; k = 1; N = 24; ZSRDS: mean 32.00, SD 8.00, n = 12 vs mean 43.00, SD 14.00, n = 12; MD ‐11.00, 95% CI ‐20.12 to ‐1.88; k = 1; N = 24).

At the six‐month (24‐week) follow‐up assessment, although there was no significant treatment effect for depression according to the ZSRDS (mean 34.00, SD 8.00, n = 12 vs mean 41.00, SD 13.00, n = 12; MD ‐7.00, 95% CI ‐15.64 to 1.64; k = 1; N = 24), BDI scores did show an effect (mean 4.00, SD 6.00, n = 12 vs mean 13.00, SD 11.00, n = 12; MD ‐9.00, 95% CI ‐16.09 to ‐1.91; k = 1; N = 24).

7.11 Hopelessness

No data available.

7.12 Suicidal ideation

There was no evidence of a significant effect for behaviour therapy on the number of patients reporting suicidal ideation at the 24‐month follow‐up assessment (5/12 vs9/12; OR 0.24, 95% CI 0.04 to 1.36; k = 1; N = 24).

7.13 Problem solving

No data available.

7.14 Suicide

No data available.

7.15 Repetition of SH

For the overall SUPRE‐MISS cohort, data from Bertolote 2010 indicated there was no evidence for a significant treatment effect for information and support on repetition of SH by the 18‐month follow‐up assessment (66/863 vs 60/800; OR 1.02, 95% CI 0.71 to 1.47; k = 1; N = 1663). This outcome was associated with low quality of evidence according to the GRADE criteria (see summary of findings Table 7).

Data on repetition of SH were also available for males and females separately. Overall, across all five sites, there was no evidence of a significant treatment effect on repetition of SH by the 18‐month follow‐up assessment in either males (30/349 vs 27/340; OR 1.09, 95% CI 0.63 to 1.88; k = 1; N = 689) or females (36/514 vs 33/460; OR 0.97, 95% CI 0.60 to 1.59; k = 1; N = 974).

Data on repetition of SH by the 18‐month follow‐up assessment were also available for each of the five countries separately. Although there was no significant difference between groups for the individual sites in Campinas, Brazil (21/71 vs 10/64; OR 2.27, 95% CI 0.97 to 5.28; k = 1; N = 135), Colombo, Sri Lanka (3/130 vs 5/121; OR 0.55, 95% CI 0.13 to 2.34; k = 1; N = 251), Karaj, Iran (33/303 vs 28/298; OR 1.18, 95% CI 0.69 to 2.00; k = 1; N = 601), and Yuncheng, China (1/58 vs 0/38; OR 2.01, 95% CI 0.08 to 50.60; k = 1; N = 96), significantly fewer participants in the experimental group had repeated SH by the 18‐month follow‐up period at the Chennai, India site (8/301 vs 17/260; OR 0.39, 95% CI 0.17 to 0.92; k = 1; N = 561). Quality of evidence for these five sites varied from very low to low (see summary of findings Table 7).

Breaking results down by gender revealed no significant effect for information and support on repetition of SH by the 18‐month follow‐up assessment for either gender at either of the five study sites [Campinas, Brazil: males 4/21 vs. 3/25; OR 1.73, 95% CI 0.34 to 8.76; k = 1; N = 46 versus females 17/50 vs. 7/39; OR 2.35, 95% CI 0.86 to 6.44; k = 1; N = 89; Chennai, India: males 5/148 vs. 7/125; OR 0.59, 95% CI 0.18 to 1.91; k = 1; N = 273 versus females 3/153 vs. 10/153; OR 0.29, 95% CI 0.08 to 1.06; k = 1; N = 306; Colombo, Sri Lanka: males 1/54 vs. 3/53; OR 0.31, 95% CI 0.03 to 3.12; k = 1; N = 107 versus females 2/76 vs. 2/68; OR 0.89, 95% CI 0.12 to 6.51; k = 1; N = 144; Karaj, Islamic Republic of Iran: males 19/109 vs. 14/118; OR 1.57, 95% CI 0.74 to 3.31; k = 1; N = 227 versus females 14/194 vs. 14/180; OR 0.92, 95% CI 0.43 to 1.99; k = 1; N = 374; Yuncheng, China: males: 1/17 vs. 0/19; OR 3.55, 95% CI 0.14 to 93.01; k = 1; N = 36 versus females 0/41 vs. 0/38; OR not calculable; k = 1; N = 79].

Hassanzadeh 2010 reported data on frequency of SH for one sub‐sample at the six‐month follow‐up assessment in Karaj, Iran. In this sample, there was evidence of a significant increase in frequency of repetition of SH in the information and support group relative to the TAU group (mean 1.63, SD 1.19, n = 319 vs mean 1.17, SD 0.38, n = 310; MD 0.46, 95% CI 0.32 to 0.60; k = 1; N = 629). Quality of evidence for this outcome was low (see summary of findings Table 7).

7.16 Treatment adherence

No data available.

7.17 Depression

Correspondence with authors revealed that information on depression was recorded at one site only: Yuncheng, China (reported by Xu 2012). Information and support was associated with a significant treatment effect for depression scores at this site by the 18‐month follow‐up assessment (mean 2.51, SD 3.25, n = 57 vs mean 5.60, SD 9.25, n = 54; MD ‐3.09, 95% CI ‐5.70 to ‐0.48; k = 1; N = 111).

7.18 Hopelessness

No data available.

7.19 Suicidal ideation

No data available.

7.20 Problem solving

Correspondence with authors revealed that information on problem solving was reported for one site only: Yuncheng, China (reported in Xu 2012). There was evidence of a significant treatment effect for information and support at this site by the 18‐month follow‐up assessment (mean 0.64, SD 0.29, n = 57 vs mean 0.52, SD 0.30, n = 54; MD 0.12, 95% CI 0.01 to 0.23; k = 1; N = 111).

7.21 Suicide

In the overall SUPRE‐MISS cohort, as reported in the primary study reference (Fleischmann 2008), there was evidence of a significant treatment effect for information and support on suicide by the 18‐month follow‐up period (2/872 vs 18/827; OR 0.10, 95% CI 0.02 to 0.45; k = 1; N = 1699).

Data on suicides were also available for three of the five study sites in related publications: Vijayakumar 2011 reported data from Chennai, India, Hassanzadeh 2010 from Karaj, Iran, and Xu 2012 from Yuncheng, China. There was evidence of a significant treatment effect for information and support on suicides by the 18‐month follow‐up assessment at the Chennai, India site (1/302 vs 9/320; OR 0.11, 95% CI 0.01 to 0.91; k = 1; N = 622) but not at either the Karaj, Iran (2/319 vs 2/310; OR 0.97, 95% CI 0.14 to 6.94; k = 1; N = 629) or the Yuncheng, China (0/57 vs 2/54; OR 0.18, 95% CI 0.01 to 3.89; k = 1; N = 111) sites.

Notably, the number of completed suicides in the experimental group reported for these three subsamples is greater than the number reported for the overall SUPRE‐MISS cohort in the primary study reference (i.e., Fleischmann 2008). We were unable to confirm the correct number of completed suicides in the experimental group with the authors. Including the one additional suicide for the experimental group identified from the three subsample publications with the data reported in the primary study reference, however, did not materially affect the result obtained for the overall SUPRE‐MISS cohort.

7.22 Repetition of SH

There was no evidence of a significant treatment effect for treatment for alcohol misuse on repetition of SH by the six‐month follow‐up period (7/52 vs11/51; OR 0.57, 95% CI 0.20 to 1.60; k = 1; N = 103). This was associated with a moderate quality of evidence (see summary of findings Table 7).

7.23 Treatment adherence

The study authors report that only 47.1% of those randomised to the experimental group attended the brief alcohol treatment session (Crawford 2010, p.1826). However, as corresponding numbers were not available for the control group, who did not receive an invitation to a brief alcohol treatment session, we could not calculate treatment effect sizes for this outcome.

7.24 Depression

No data available.

7.25 Hopelessness

No data available.

7.26 Suicidal ideation

No data available.

7.27 Problem solving

No data available.

7.28 Suicide

Correspondence with authors confirmed that no participants died by suicide in either group over the course of the six‐month follow‐up period. However, the authors warn that as they were unable to track participants via their National Health Service (NHS) identity numbers, they were unable to confirm numbers of suicides from national mortality data. Thus, there may have been suicides amongst those participants whom the authors were unable to contact by the six‐month follow‐up assessment.

7.29 Repetition of SH

There was no evidence of a significant treatment effect for home‐based problem‐solving therapy on repetition of SH by the 12‐month follow‐up assessment (5/48 vs 7/48; OR 0.68; 95% CI 0.20 to 2.32; k = 1; N = 96). Quality of evidence, as assessed using the GRADE criteria, was moderate for this outcome (see summary of findings Table 7).

7.30 Treatment adherence

There was, however, a significant treatment effect for home‐based problem‐solving therapy on the number of participants who attended at least one treatment session over the course of the 12‐month follow‐up period (45/48 vs 35/48; OR 5.57, 95% CI 1.47 to 21.08; k = 1; N = 96).

7.31 Depression

Although this trial included data on depression, the authors modified the scale used (Lorr and McNair Mood Scale; McNair 1964; Lorr 1967), thereby precluding inclusion of this data in this review.

7.32 Hopelessness

No data available.

7.33 Suicidal Ideation

Data obtained by correspondence suggested there was no significant treatment effect for suicidal ideation at either the post‐treatment assessment (Mann‐Whitney U = 984, P = 0.29) or six‐month follow‐up (Mann‐Whitney U = 726, P = 0.14). As only median, rather than mean, scores were available for this outcome, we were unable to reproduce the mean difference in suicidal ideation scores between the experimental and control groups in this review.

7.34 Problem solving

No data available.

7.35 Suicide

No data available.

7.36 Repetition of SH

There was no evidence of a significant treatment effect for intensive inpatient and community treatment on repetition of SH by the 12‐month follow‐up (24/140 vs 20/134; OR 1.18, 95% CI 0.62 to 2.25; k = 1; N = 274). Quality of evidence, according to the GRADE criteria, was low for this outcome (see summary of findings Table 7).

With respect to frequency of repetition of SH, there was also no evidence of a significant treatment effect for intensive inpatient and community treatment (mean 0.23, SD 0.57, n = 140 vs mean 0.23, SD 0.81, n = 134; MD 0.00, 95% CI ‐0.17 to 0.17, k = 1; N = 274). Quality of evidence for this outcome was also low (see summary of findings Table 7).

7.37 Treatment adherence

There was a significant treatment effect for treatment adherence. More patients in the experimental group attended at least one outpatient treatment session by the 12‐month follow‐up assessment (119/140 vs 64/134; OR 6.99, 95% CI 3.69 to 12.36; k = 1; N = 274). However, there was no difference in the total number of treatment sessions attended (mean 14.30, SD 24.20, n = 140 vs mean 11.40, SD 27.70, n = 134; MD 2.90, 95% CI ‐3.27 to 9.07; k = 1; N = 274).

7.38 Depression

There was no significant treatment effect for intensive inpatient and community treatment on depression scores by the 12‐month follow‐up assessment (mean 30.80, SD 15.90, n = 94 vs mean 35.80, SD 16.20, n = 50; MD ‐5.00, 95% CI ‐10.52 to 0.52; k = 1; N = 144).

7.39 Hopelessness

There was no significant treatment effect for intensive inpatient and community treatment on hopelessness scores by the 12‐month follow‐up assessment (mean 6.10, SD 5.00, n = 94 vs mean 7.50, SD 5.90, n = 50; MD ‐1.40, 95% CI ‐3.32 to 0.52; k = 1; N = 144).

7.40 Suicidal ideation

No data available.

7.41 Problem solving

No data available.

7.42 Suicide

There was also no evidence of a significant treatment effect for suicide by the 12‐month follow‐up assessment (1/140 vs 2/134; OR 0.47, 95% CI 0.04 to 5.30; k = 1; N = 274).

7.43 Repetition of SH

There was no evidence of a significant treatment effect for hospital admission on repetition of SH at the post‐intervention assessment (2/38 vs 2/39; OR 1.03, 95% CI 0.14 to 7.69; k = 1; N = 77) or by the four‐month follow‐up assessment (3/38 vs 4/39; OR 0.75, 95% CI 0.16 to 3.60; k = 1; N = 77). Quality of evidence for these time points was low (see summary of findings Table 7).

7.44 Treatment adherence

No data available.

7.45 Depression

No data available.

7.46 Hopelessness

The authors state that there was no significant difference in hopelessness scores at the post‐intervention assessment (mean 10.29, SD 5.68 vs mean 10.21, SD 4.97); however, they did not provide the numbers of patients in each group, thus precluding calculation of the MD and its associated 95% CI.

7.47 Suicidal ideation

There was no evidence of a significant treatment effect for hospital admission on suicidal ideation scores by the four‐month follow‐up assessment (mean 0.22, SD 0.85, n = 27 vs mean 0.04, SD 0.20, n = 25; MD 0.18, 95% CI ‐0.15 to 0.51; k = 1; N = 52).

7.48 Problem solving

No data available.

7.49 Suicide

No data available.

7.50 Repetition of SH

There was no evidence of a significant treatment effect for intensive intervention on repetition of SH by either the four‐month (Welu 1977: 3/62 vs 9/57; OR 0.27, 95% CI 0.07 to 1.06; k = 1; N = 119) or 24‐month (Allard 1992: 22/63 vs 19/63; OR 1.24, 95% CI 0.59 to 2.62; k = 1; N = 126) follow‐up assessments. For both follow‐up periods, quality of evidence was low(see summary of findings Table 7). We combined the results of these two trials, and again there was no evidence of a significant treatment effect for intensive outpatient intervention by the final follow‐up point (Analysis 6.1; k = 2; N = 245). The quality of evidence was very low for this outcome (see summary of findings Table 7).

In the one trial that reported information on frequency of SH over the course of the 24‐month follow‐up period (i.e., Allard 1992), "the experimental subjects did not make fewer attempts than the comparison subjects" (Allard 1992, p. 310).

7.51 Treatment adherence

Data on treatment adherence were only available for Allard 1992. However, as the authors did not report information on SDs, t‐test or F statistics we were unable to impute SDs using the method outlined in Townsend 2001 to calculate the mean difference in the number of treatment sessions attended. Nevertheless, the authors themselves report that "[t]he mean numbers of encounters with psychiatrists were 12.35 versus 1.54 (P < 0.001) in the first year and 2.11 versus 0.64 (P = 0.071) in the second year" (Allard 1992, p. 311).

7.52 Depression

No data available.

7.53 Hopelessness

No data available.

7.54 Suicidal ideation

No data available.

7.55 Problem solving

No data available.

7.56 Suicide

Allard 1992 reported data on suicide during follow‐up. There was no evidence of a significant treatment effect for the intensive outpatient intervention on suicides, however, by the 24‐month follow‐up assessment (3/76 vs 1/74; OR 3.00, 95% CI 0.30 to 29.52; k = 1; N = 150) in this trial.

7.57 Repetition of SH

There was no evidence of a significant treatment effect for long‐term therapy on repetition of SH by the post‐treatment assessment (9/40 vs 9/40; OR 1.00, 95% CI 0.35 to 2.86; k = 1; N = 80). A low quality of evidence was associated with this outcome (see summary of findings Table 7).

7.58 Treatment adherence

The authors did not provide numerical data on treatment adherence, although they state, "[a]ttendance at the first session was about equal for both groups (about 60%)" (Torhorst 1988, p. 420). However, the authors further state that "participation of the 12‐month (long‐term therapy) group dropped drastically by the second session to under 40%, while the participation of the patients in the 3‐month (intensive short‐term therapy) program remained higher" (Torhorst 1988, p. 420). It is unclear whether this difference was significant.

Overall adherence also appears to have been very low in both groups as the "average number of sessions was 3.9 (out of a possible 12 sessions) in the three‐month group and 2.6 (out of a possible 12 sessions) for the 12‐month group" (Torhorst 1988, p.420). Again, it is unclear whether this difference is significant. Additionally, as neither SDs, nor t‐test, nor F statistics were reported, we were unable to impute SDs using the method outlined in Townsend 2001 to calculate the mean difference in the number of treatment sessions attended by the experimental and control groups.

7.59 Depression

Although numerical data on depression scores were not available, means estimated by the review authors from a graph in the original report suggest there was little difference in depression scores between those allocated to long‐term therapy and those allocated to short‐term therapy by the 12‐month follow‐up assessment (estimated means 9.3 vs 6.7).

The study authors, however, stated that "self‐evaluated depressivity. . . improved considerably more for the patients of the three‐month program than for those of the 12‐month program" (Torhorst 1988, p. 421). This improvement was described by the authors as significant.

7.60 Hopelessness

No data provided.

7.61 Suicidal ideation

No data provided.

7.62 Problem solving

No data provided.

7.63 Suicide

No data provided.