[Assessment and clinical management of self-harm in adolescence: evidence-based protocol]
Alvarez Ariza M, Bilbao Garmendia E, Guitián Rodríguez D, Jiménez Pulido I, Mazaira Castro JA, Núñez Iglesias S, Pascual Mateos JC, Rodriguez Lombardia A, Triñanes Pego Y, Vega Moreno D
Record ID 32018004229
Original Title: Evaluación y manejo clínico de las autolesiones en la adolescencia: protocolo basado en la evidencia
Authors' objectives: The general aim is to prepare a document based on scientific evidence in order to favour a better assessment and clinical management of self-harm in adolescence. The specific objectives are: - To review the scientific evidence on the assessment and clinical management of self-harm (with and without suicidal intent). - To develop diagnostic-therapeutic algorithms that can be used by professionals to improve the care provided in the Spanish National Health System (NHS) to adolescents with self-harm and reduce variability, as well as to facilitate coordination between different professionals and levels of care. - To develop indicators that can be used to monitor the care provided to these patients. - To suggest lines of future research. - To draw up an information document for adolescents, families and education professionals.
Authors' results and conclusions: We selected 5 CPGs and 10 SRs (2 on risk factors, 3 on assessment tools, 3 on clinical management and 2 on the experiences and information and support needs of patients and their families), which met both the inclusion/exclusion criteria for answering the questions posed and the established levels of methodological quality. The overall quality of the CPGs was moderate and that of the systematic reviews ranged from low to high. With regard to assessment, there is consensus that the main method of collecting information should be the clinical interview, as although there are different scales designed for assessing and predicting the risk of self-harm, according to the scientific evidence none of them can be used as the only method of assessment, but instead as a complement to the clinical interview. It is important to assess risk factors that have been associated with repeated self-harm, such as the presence of mental disorders, psychological factors (suicidal ideation, hopelessness, emotional distress, emotional dysregulation), high family dysfunctionality and peer rejection. At the health care level, a psychosocial assessment should be carried out in primary care, taking into account the main risk factors. When the levels of distress in the adolescent or their family are high, there is a risk of repetition, or the person themselves requests it, it should be considered that referral to the mental health service is a priority. Although there are different psychological interventions that have obtained beneficial results in the reduction of self-harm and other variables related to suicidal behaviour, the available scientific evidence does not allow us to establish which psychotherapy has the best profile of effectiveness. The available guidelines recommend psychological treatment as the first line of action, specifically cognitive-behavioural, dialectical-behavioural and mentalisation therapies. Pharmacological treatment is not recommended as a specific intervention to reduce self-harm, except in cases with comorbid psychopathology. Qualitative studies on the experiences of patients and their families show that suicidal behaviour is associated with significant distress in adolescents and those close to them. Adolescents often describe feelings of depression, worthlessness, self-hatred, self-loathing and emptiness, while family members report helplessness, guilt, anger and lack of control. No scientific evidence has been identified that specifically addresses the experience of non-suicidal self-harming adolescents and their families. Currently, self-harm is a serious problem in the adolescent population and, therefore, it is important to establish mechanisms that allow for its appropriate detection and clinical management. This document summarises the most relevant evidence, as well as the main actions in primary and specialised care, with the aim of guiding professionals and favouring shared decision-making. Indicators for monitoring clinical practice are also proposed and a document for adolescents, families and education professionals has been prepared. Future research should focus on evaluating the effectiveness of different interventions and designing new preventive and therapeutic approaches.
Authors' methods: A multidisciplinary working group was formed comprising professionals from specialties involved in the clinical management of self-harm in adolescence, including family medicine, paediatrics, mental health nursing, clinical psychology and psychiatry. The working group was also attended by patient representatives. A systematic review approach of Clinical Practice Guidelines (CPG) and Systematic Reviews (SR) was followed, and the methodology for the elaboration of evidence-based protocols and CPG in the Spanish National Health System (NHS) was taken into account. After a preliminary search to define the scope of the project in November 2020, a search for CPGs and systematic reviews was conducted in May 2021. The following databases and portals were searched: G-I-N, Tripdatabase, CPGinfobase, ECRI guidelines, CMAJ, NICE, Cochrane Library, Medline, APA PsycINFO, Embase and CINAHL. The analysis and selection of studies was carried out by two reviewers independently. The assessment of quality and risk of bias was carried out using different instruments: AGREE-II (for CPGs), AMSTAR-2 (for SRs) and ENTREQ (for SRs of qualitative studies). The assessment of the overall quality of the evidence was carried out following an approach based on the GRADE methodology (Grade of Recommendations, Assessment, Development and Evaluation). The working group analysed the results of the systematic review and based on the scientific evidence, diagnostic-therapeutic algorithms were defined for primary care and specialised care. In addition, assessment indicators were proposed by consensus of the working group, recommendations for future research were made, and a document for adolescents, families and education professionals was produced. The draft document went through an external review process carried out by experts proposed by the main scientific societies and patient associations.
Project Status: Completed
Year Published: 2022
URL for published report: http://hdl.handle.net/20.500.11940/17301
English language abstract: An English language summary is available
Publication Type: Other
- Harm Reduction
- Self-Injurious Behavior
- Psychosocial Intervention
Organisation Name: Scientific Advice Unit, avalia-t; The Galician Health Knowledge Agency (ACIS)
Contact Address: Conselleria de Sanidade, Xunta de Galicia, San Lazaro s/n 15781 Santiago de Compostela, Spain. Tel: 34 981 541831; Fax: 34 981 542854;
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Copyright: <p>Galician Agency for Health Technology Assessment (AVALIA-T)</p>
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