OBJECTIVE:Second-generation antipsychotic (SGA) treatment has increased in youth globally. However, the effects of these agents on real-world outcomes are largely unknown, especially for non-approved indications. METHOD:This study included a national cohort of incident SGA recipients 7 to 17 years of age in Sweden from 2007 to 2020. Youth were followed from 1 year before SGA initiation through up to 1 year afterward, and in recurrent treatment analyses, up to 13 years after initiation. Within-individual comparisons were used to examine the risk of psychiatric hospitalization, self-harm, accidental injury, and violent crime before and after treatment. RESULTS:The study included 21,306 SGA initiators (53.1% male; median age 14.8 years at baseline). Indications included psychosis-related disorders (1,966 [9.2%]), autism spectrum disorders (5,140 [24.1%]), depression/other mood disorders (3,669 [17.2%]), intellectual disability (987 [4.6%]), and attention-deficit/hyperactivity disorder (2,992 [14.0%]). Within a year of initiation, 5,604 (26.3%) experienced psychiatric hospitalization, 1,749 (8.2%) self-harm, 954 (13.6% of those ≥16 years of age) violent crime, and 3,134 (14.7%) accidental injury. Risks were generally elevated immediately before SGA initiation and decreased across subsequent treatment without fully returning to baseline, although there was variation across indications. For example, psychiatric hospitalization and self-harm displayed larger pre-initiation elevations and subsequent decreases for youth with psychosis-related disorders (eg, psychiatric hospitalization: pre-initiation odds ratio [ORpre] = 11.30 [95% CI, 9.84-12.97]; ORpost = 2.59 [95% CI = 2.21-3.02]). Conversely, youth with neurodevelopmental disorders demonstrated greater decreases in violent crime (eg, attention-deficit/hyperactivity disorder: ORpre = 1.66 [95% CI, 1.23-2.26]; ORpost = 1.26 [95% CI, 0.94-1.70]). Accidental injury risk did not statistically significantly differ (eg, ASD: ORpost = 0.90 [95% CI, 0.77-1.07]). CONCLUSION:After having escalated before initiation, risk of psychiatric hospitalization, self-harm, and violent crime decreased during SGA treatment without fully returning to baseline. There was little evidence of associations with accidental injury.

Introduction Mental health conditions are prevalent during adolescence, but access to early evidence-based treatments remains limited. Scalable, online, theory-based transdiagnostic interventions delivered in primary care have the potential to reduce this treatment gap, but the effectiveness remains unknown. The objective is to investigate whether an online transdiagnostic emotion regulation treatment for adolescents with mental health conditions is superior to an active control treatment. Methods and analysis This single-blind, randomised clinical superiority trial will evaluate the effectiveness and cost-effectiveness of an online transdiagnostic emotion regulation treatment for adolescents with mental health conditions within primary care in Sweden. We aim to include 388 participants (adolescents aged 12–17 years with mental health conditions and their parents), recruited through primary care and self-referral. Patients will be randomised to either an online transdiagnostic emotion regulation treatment or an active control treatment. Participants will receive 6 weeks of therapist-guided online transdiagnostic emotion regulation treatment or an active control treatment consisting of 6 weeks of online supportive treatment. Parents will participate in parallel with their adolescents in both conditions and will receive an online parent course. The primary outcome, assessed by blinded assessors, will be clinical global symptom severity measured with the Clinical Global Impressions-Severity scale. Treatment effectiveness will be evaluated through blinded assessment and self-assessment at primary endpoint (immediately after treatment) and 3 months after treatment. In addition, a health economic evaluation will be conducted. The study will be undertaken between October 2023 and July 2026. Ethics and dissemination The study has obtained ethical approval from the Swedish Ethical Review Authority. Findings will be disseminated in peer-reviewed publications and presented at scientific conferences. Trial registration number NCT06067165 .

ObjectiveWorkforce training is a widely used implementation strategy to improve care within mental health services, yet evidence for sustained changes in clinical practice remains inconsistent. Managerial actions are likely critical for translating training into practice, but little is known about how leaders conceptualize training objectives or which mechanisms of change they rely on. This study examined which outcomes mental health managers value from clinical staff training and the strategies they use to support effectiveness.MethodIn-depth interviews were performed with 14 managers from eight Swedish regions, and data were analyzed using two forms of qualitative content analysis: Training objectives were inductively coded into categories, while reported strategies were deductively organized using an operant learning framework to identify behavior-change mechanisms.ResultsManagers described training as serving multiple purposes organized in two overarching aims: Care Delivery Goals, including clinical impact and service provision, and Work Environment Goals, encompassing staff wellbeing and connectedness among colleagues. Reported strategies aligned with the four predefined categories—Antecedents, Monitoring, Consequences, and Processes & Resources—and one additional category developed during coding: Preparatory strategies. Across strategies, mechanisms essential for sustaining new skills, such as task clarification, outcome monitoring, and performance-contingent feedback, were inconsistently applied.ConclusionsThis study demonstrates that leaders attribute a wider range of purposes to workforce training than is typically assumed in training and implementation research, encompassing not only clinical or competence-related outcomes but also central work environment and organizational goals. An operant analysis of their strategies clarifies the change mechanisms managers rely on and highlights the importance of intentional, strategic-level actions—including preparatory strategies that shape who is trained, in what, and why. Furthermore, the findings inform practical recommendations that emphasize linking training initiatives to organizational priorities and systematically employing strategies such as monitoring, feedback, and task clarification. Integrating these elements can strengthen the design, implementation, and long-term impact of staff training, ultimately supporting better patient outcomes, improved staff wellbeing, and more effective use of limited resources.

IntroductionPatient-Controlled Admission (PCA) is an intervention aimed at increasing patient autonomy by allowing patients to admit themselves to psychiatric inpatient stays without physician assessment or staff gatekeeping. PCA is intended for patients with recurrent need of inpatient care, potentially those who would benefit from increased influence over the admission process. Studies suggest PCA may reduce involuntary care and improve patient empowerment. However, findings are difficult to interpret due to variation in implementation, lack of fidelity assessments, and the absence of an objective fidelity instrument.AimTo develop and evaluate a fidelity measure for PCA capturing core standards of fidelity across clinical settings while remaining acceptable and user-friendly in routine practice.MethodsThe development process of the fidelity instrument for chart review followed a five-step method: reviewing existing measures, analysing intervention components, drafting a fidelity checklist and guidelines, obtaining expert feedback, and piloting and refinement. Interrater reliability was assessed using Fleiss’ Kappa and percentage agreement, and acceptability and user-friendliness was evaluated in a routine clinical setting using Likert-scale questions.ResultsThe Patient-Controlled Admission Fidelity Checklist (PCA-FC) consists of three parts: A1 (PCA as part of the care plan), A2 (the PCA-agreement), and B (PCA inpatient care). Item-level percentage agreement ranged from 90% to 100%, with several items demonstrating complete agreement. Fleiss’ Kappa coefficients ranged from non-estimable variables for items with no response variability to perfect agreement (κ =1.00). The PCA-FC demonstrated strong acceptability and usability indicating that the checklist was perceived as easy to understand, complete, and apply in practice. Fidelity scores aggregated at the organisational level showed variation, with the lowest adherence observed in inpatient care items.ConclusionThe PCA-FC demonstrated high reliability for assessment of PCA fidelity through chart review. It may serve as a useful tool for implementation monitoring, clinical quality assurance, and research on effectiveness of PCA in psychiatric settings. However, fidelity is a multidimensional construct, and the PCA-FC represents an initial step in fidelity assessment that should be complemented by additional methods and further validation.

BACKGROUND:Most individuals diagnosed with borderline personality disorder (BPD) use psychotropic medications. BPD symptom severity is elevated in young adulthood, but medication utilisation studies in young adults with BPD are lacking. AIMS:To investigate the use of central nervous system (CNS) acting medications among young adults (aged 18-24), who were diagnosed with BPD, focusing on the years around the first established diagnosis. METHODS:A cohort study of all individuals with a registered BPD diagnosis in Sweden was conducted using national population register data. Dispensed prescriptions between July 2005 and June 2020 were utilised. Prevalent use, long-term use, and co-medication were investigated during specific 1-year periods: the year before, and then the first, second, and third year after diagnosis. RESULTS:Medication use peaked for all three measures in the year following the first BPD diagnosis: 90.3% used CNS-acting medication during that year, and antidepressants were the most used group (70.1%). Furthermore, 74.5% used medication for >12 months, and 34.8% used ⩾3 medication groups in co-medication. Compared to a reference group of individuals diagnosed with depression, the BPD group used more medication. In the depression group, 87.5% used medication, 55.2% used medication for >12 months, and 3.8% used ⩾3 medication groups in co-medication. Moreover, medication use increased from 2006 to 2019. CONCLUSION:This indicates the importance of continuously evaluating risks and benefits with medication use, and in having easy access to up-to-date guidance about best clinical practice for individuals diagnosed with BPD, to facilitate appropriate and safe medication use.

Background Non-suicidal self-injury (NSSI) among adolescents is linked to adverse outcomes for youth and their families. While parental involvement is considered essential in treating adolescent NSSI, the effects on parents remain unclear.Objective To evaluate if Internet-delivered Emotion Regulation Individual Therapy for Adolescents (IERITA) adjunctive to treatment as usual (TAU) is superior to TAU alone in improving parental coping with adolescents’ negative emotions, the durability of potential effects and whether reductions in parents’ minimising of their adolescent’s emotions mediate adolescent outcomes.Methods 166 adolescents with NSSI disorder (93% female; mean (SD) age=15.0 (1.2) years) and their parents (83% female; mean (SD) age=46.5 (5.1) years) were randomised to IERITA plus TAU (n=84) or TAU-only (n=82). IERITA is a 12-week, therapist-guided emotion regulation behavioural therapy, including both adolescents and parents. In parallel to the adolescent, parents participate in a separate internet-delivered course designed to provide skills for understanding and supporting their adolescent. The outcomes were parental coping measured by the Coping with Children’s Negative Emotions Scale-Adolescent version, including minimisation (primary outcome), distress, punitive and expressive encouragement responses at baseline, post-treatment (primary endpoint) and 3 months post-treatment. Parental minimisation was tested as a mediator of adolescent NSSI absence and emotion regulation difficulties.Findings There were statistically significant treatment effects on parental minimisation and distress responses at post-treatment and 3 months post-treatment, and punitive responses at 3 months post-treatment, favouring IERITA. Parental minimisation did not mediate adolescent NSSI absence or emotion regulation difficulties.Conclusion IERITA shows promise for supporting parents of youth with NSSI. Further studies are needed to understand how parental improvement may impact youth with NSSI.Clinical implications Online family treatment for NSSI can improve how parents handle their adolescents’ emotions.Trial registration number NCT03353961.

ABSTRACT Background Individuals who engage in non‐suicidal self‐injury (NSSI) exhibit reduced pain sensitivity compared to the general population. It has been argued that this hypoalgesic characteristic may be attributable to hyper‐effective pain modulation. However, empirical support for this theory remains inconsistent. The aim of the study was to use a combined offset analgesia (OA) and onset hyperalgesia (OH) protocol to investigate if women with NSSI have a propensity to inhibit nociceptive signals to a higher degree (stronger OA response) and facilitate nociceptive signals to a lesser degree (weaker OH response), compared to a control group. Methods Data was collected from 76 women, 18–35 age (37 with NSSI and 39 healthy controls). The OA and OH protocol were combined with functional magnetic resonance imaging (fMRI). Results The NSSI group displayed a weaker OH response, compared to the control group. This suggests that women with NSSI do not facilitate nociceptive signals to the same extent as healthy women. However, there were no significant differences between the groups regarding OA. Across all participants, we observed stronger activation in the primary sensory cortex during the OH condition, compared to the control condition. Conclusions The results offer partial support for the general hypothesis that women with NSSI demonstrate enhanced pain modulation. The fMRI finding requires replication.

Objectives: Psychological inflexibility (PI) is a potentially important yet understudied factor in therapist training, as it may hinder engagement in learning activities central to psychotherapy education and is negatively associated with learner wellbeing. However, few instruments have been developed to assess PI in educational and training contexts, and evidence from psychotherapy training populations are limited. This study aimed to develop a new measure of PI intended for use in educational settings, and to evaluate its psychometric properties within the specific context of psychotherapy training. Method: In Study One, an initial version of the scale was developed and tested with 195 mental health professionals who were currently or previously enrolled in psychotherapy continuing education. Preliminary psychometric evaluation included expert review, cognitive interviews, exploratory factor analysis, and Mokken scale analysis. Rasch methodology was then applied to assess dimensionality, item independence, response category ordering, targeting, invariance, and reliability. In Study Two, a new sample (n = 337) was used to validate the revised instrument through Rasch analysis. Results: Results supported a unidimensional, 7-item scale demonstrating good model fit, local independence, ordered thresholds, invariance, and acceptable reliability. Additional analyses suggested a small but statistically significant negative association between age and psychological inflexibility (rho =-0.18), while no consistent differences were found across gender or profession. Conclusion: The resulting instrument-the Karolinska Inner-Barriers Scale for Education (KIBS-Ed)-offers a brief and psychometrically sound measure of psychological inflexibility, suitable for use in educational and training settings. Our evaluation within two samples from the psychotherapy training population supports its application within therapist education. Despite providing only preliminary validation and requiring further evaluation with additional outcomes and instruments, the present study represent a rigorous and important first step.

Non-suicidal self-injury (NSSI) is a public health concern and a widespread behaviour, especially among adolescents. NSSI is an indicator of psychological distress and a known risk factor for later suicidal behaviour and death by suicide; however, evidence-based treatment options and early interventions specifically for NSSI in adolescents are sparse. The aim of the TEENS multi-site randomised clinical trial is to investigate the benefits and harms of the 11-week IERITA programme (Internet-based Emotion Regulation Individual Therapy for Adolescents) added to treatment as usual (TAU) versus TAU alone in 13- to 17-year-old patients with NSSI referred to psychiatric outpatient services in four out of five Danish regions. Here, we present a combined protocol paper and statistical analysis plan for the TEENS multi-site trial. The TEENS multi-site trial is an investigator-initiated, two-arm, parallel-group randomised clinical superiority trial with blinded outcome assessment. IERITA is provided as an add-on treatment to TAU and compared with TAU alone. IERITA is a therapist-guided, internet-delivered intervention for adolescents teaching emotion regulation skills and includes a complementary part for parents. Participants are randomly allocated in a 1:1 ratio, stratified by trial site and past-month NSSI episodes at baseline (1–10 compared to ≥11 episodes). The primary outcome is NSSI episodes within the past month measured by the Deliberate Self-Harm Inventory Youth version (DHSI-Y). Secondary outcomes include quality of life (KIDSCREEN-10), symptoms of depression, anxiety, and stress (DASS-21), and the proportion of participants with any past-month NSSI. Both primary and secondary outcomes are measured at the end of the intervention (12 weeks). Analyses will be conducted according to the intention-to-treat principle. This paper presents the design and statistical analysis plan for the TEENS multi-site trial. Publishing these considerations before inclusion of the last participant helps increase transparency and limit bias. The trial is approved by the Regional Ethics Committee in the Capital Region of Denmark (H-21035306; 1 February 2022, protocol version 1.3) and the Regional Data Protection Agency (P-2020-113; 8 September 2021). The trial is registered on ClinicalTrials.gov (identifier: NCT05179655; 5 January 2022).

BACKGROUND:Self-harm is a prevalent health concern among youths, with significant psychosocial impacts on both youths and their parents. The aim of this study is to describe the impact of offspring self-harm on parental work absence. METHODS:This cohort study included 176 472 mothers and 161 833 fathers of 17 726 youths with a first self-harm diagnosis between the years of 2006 and 2016 and 177 260 matched youths without self-harm. It examined work absence due to family leave to care for a sick child and sick leave, before and after the child's self-harm. Data were sourced from Swedish population-based registers. Conditional Poisson regression, adjusting for potential confounders, was used to analyse associations between self-harm and work absence in parents of youth with and without self-harm after the self-harm event, as well as in parents of self-harming youth before and after the self-harm event. RESULTS:Parents of both sexes experienced work absence. Nevertheless, mothers were particularly affected. Youth self-harm was linked to increased family leave (rate ratios: mothers 3.47 (95% CI 3.25 to 3.72), fathers 2.71 (2.47 to 2.98)) and sick leave (mothers 1.25 (1.20 to 1.31), fathers 1.25 (1.17 to 1.33)). Parents of affected youth took more family leave during the self-harm year compared with the previous year (mothers 1.65 (1.55 to 1.75), fathers 1.41 (1.29 to 1.54)), with no corresponding rise in sick leave. CONCLUSIONS:Parents of self-harming youths experience increased work absence, especially family leave, peaking around self-harm events. These results highlight the broader impact of youth self-harm on families and the need for support systems addressing both youth and caregiver well-being and work-life balance.

BACKGROUND:Individuals who engage in nonsuicidal self-injury (NSSI) have a reduced pain sensitivity. Self-induced pain is attenuated compared with externally induced pain, and this phenomenon, sensory attenuation, could partly explain the insensitivity to pain in individuals with NSSI. METHODS:The objective was to assess sensory attenuation in women with NSSI compared to controls. In total, 81 women aged 18-35 years, mean age 23.4 (SD = 3.9), with NSSI (n = 41) or controls (n = 40) were recruited in this cross-sectional study. Self-induced and experimenter-induced pressure pain thresholds were assessed. Correlation tests assessed possible associations between sensory attenuation and NSSI frequency, NSSI duration and conditioned pain modulation. RESULTS:Across groups, the average self-induced pressure pain was 164.8 kPa (SE = 25.2, 95% CI = 114.8-214.7) higher than the average experimenter-induced pressure pain (d = 0.66). On average, NSSI participants displayed 106.7 kPa (SE = 42.9, 95% CI = 21.7-191.8) higher pressure pain thresholds than controls (d = 0.42), but there was no significant interaction effect for group (NSSI vs. controls) and condition (self-induced vs. experimenter-induced pain) (p = 0.102). However, a greater number of NSSI participants than controls were identified as exhibiting sensory attenuation (p = 0.022) when applying a threshold of ≥ 10% for sensory attenuation. Sensory attenuation correlated with conditioned pain modulation (tau = 0.17; p = 0.025), but not with NSSI frequency or duration. CONCLUSION:Sensory attenuation of self-induced pressure was more prevalent in participants with NSSI than in controls, but there was no evidence that sensory attenuation was related to NSSI frequency or duration. The correlation between the sensory attenuation and conditioned pain modulation may be an indication of mutual anti-nociceptive mechanisms. SIGNIFICANCE STATEMENT:Sensory attenuation of self-induced pain was present in both participants with NSSI and controls, but a greater number of NSSI participants were identified as exhibiting sensory attenuation, applying a threshold of ≥ 10% for sensory attenuation. Sensory attenuation may facilitate NSSI behaviour because when pain is attenuated, the pain barrier for engaging in self-harm will be reduced.

Mental health problems are common during adolescence, but access to effective treatments is limited. Transdiagnostic treatments could address this treatment gap, but their feasibility, acceptability, and effectiveness remain unknown. To test the feasibility and acceptability of an online emotion regulation treatment for adolescents with mental health problems and investigate the preliminary effects on clinical outcomes and the target mechanism, emotion regulation. This single-blind randomized clinical trial was conducted between October 16, 2022, and July 28, 2023, in a primary care setting in Sweden. Participants in the intention-to-treat analysis were adolescents aged 12 to 17 years with mental health problems and their parents. Participants were randomized 1:1 to 6 weeks of therapist-guided online transdiagnostic emotion regulation treatment or an active control condition consisting of 6 weeks of online supportive treatment. The primary outcomes were feasibility and acceptability measures, including consent rate, completion of assessments, adherence, credibility and expectancy ratings (Credibility/Expectancy Questionnaire), and treatment satisfaction (Client Satisfaction Questionnaire), immediately after treatment. Clinical outcomes, rated by blinded assessor, included global symptom severity and improvement, symptoms of depression and anxiety, global functioning, and emotion regulation. A total of 30 adolescents (mean [SD] age, 14.2 [1.48] years; 28 females [93%]) were randomized to experimental treatment (n = 15) or active control treatment (n = 15). The consent rate (30 of 37 eligible participants [81%]) and rate of assessment completion immediately after treatment (28 [93%]) were high. Adherence, credibility, expectancy, and satisfaction in both groups were adequate. Participation in the experimental condition, but not the control condition, was associated with large within-group reductions in symptom severity (effect size, 1.30; 95% CI, 0.73-1.86) and symptoms of anxiety and depression (Cohen d, 1.07; 95% CI, 0.37-1.84), improved global functioning (Cohen d, 1.26; 95% CI, 0.66-1.85), and reductions in maladaptive cognitive coping (Cohen d, 1.10; 95% CI, 0.52-1.70) immediately after treatment. In this randomized clinical trial, a brief online transdiagnostic emotion regulation treatment targeting adolescents with mental health problems was found to be feasible, acceptable, and potentially efficacious in primary care and may increase treatment outreach and accessibility for this population. ClinicalTrials.gov Identifier: NCT05032547

ABSTRACTObjectiveThe study aimed to estimate 5‐year recurrence rates of first‐episode major depressive disorder (MDD) and assess the impact of adolescence on recurrence likelihood after the first episode, compared to adults.MethodsA pre‐registered retrospective cohort study that utilized epidemiological data from the Stockholm MDD Cohort (1997–2018), including all individuals registered with a depression diagnosis in Region Stockholm from 2010 to 2018. This dataset combines longitudinal information from primary and secondary care, socioeconomic data, drug dispensations, psychotherapy sessions, brain stimulation treatments, and inpatient treatment. The study included 9124 individuals (1727 adolescents aged 13–17 and 7397 adults aged 18–40) who experienced their first MDD episode between 2011 and 2012, with at least three months of remission. Propensity score weighting balanced cohorts for biological sex, socioeconomic status, depression severity, psychiatric comorbidities, and treatments.ResultsThe 5‐year recurrence rates were 46.1% for adolescents and 49.0% for adults. The study had over 80% power to detect a minimum absolute difference in recurrence rates of approximately 5.5 percentage points. No significant difference in recurrence likelihood (p = 0.364) or time from remission to recurrence (median 379 days for adolescents, 326 days for adults, p = 0.836) was found between groups. Findings were consistent across bootstrap replicates and sensitivity analyses with extended remission periods.ConclusionsApproximately half of individuals with a first MDD episode experience recurrence within five years. Recurrence rates were higher than expected for adults but consistent with expectations for adolescents. The study underscores the need for relapse prevention from adolescence through adulthood and indicates a similar clinical course of MDD across age groups.

Background:Nonsuicidal self-injury (NSSI) is common among adolescents and is associated with adverse clinical outcomes, as well as suicidal behavior. Current treatments are resource-intensive and may not be accessible to all adolescents with NSSI. Internet-delivered emotion regulation individual therapy for adolescents (IERITA) with NSSI disorder is a promising treatment option, but its cost-effectiveness is unknown. Objective:This study aims to evaluate the cost-effectiveness of IERITA for adolescents with NSSI disorder. Methods:Within-trial cost-effectiveness analysis of a randomized controlled trial at three child and adolescent mental health services in Sweden (n=166). A total of 12 weeks of IERITA plus treatment as usual (TAU) versus TAU only were compared. The primary outcome was the frequency of NSSI at 1-month posttreatment. Secondary outcomes were NSSI remission and quality-adjusted life years (QALYs). Results:IERITA led to reductions in NSSI frequency, a higher proportion of participants with NSSI remission, and more QALYs at 1-month posttreatment, at additional health care costs of US $3663 (95% CI US $2182-$5002) and societal costs of US $4458 (95% CI US $-577 to $9509). The incremental cost of one additional NSSI remission at 1-month posttreatment was US $18,677, and the incremental cost per QALY gained was US $792,244 for IERITA+TAU relative to TAU. IERITA had an 8% probability of being cost-effective at a societal willingness-to-pay threshold of US $84,000 for one QALY at 1-month posttreatment, which increased to 18% at 3-months posttreatment. Conclusions:IERITA delivered adjunctive to TAU led to improvements in NSSI frequency, remission, and QALYs, at additional costs compared to TAU only. This study provides an estimate of the additional cost of delivering IERITA; however, future studies should include longer follow-up periods to better assess the magnitude of the effects on QALYs and societal costs.

Background Suicide attempts are common in youth and have potentially lethal outcomes. Effective treatments targeting suicide attempts are scarce.Objective To assess the feasibility and preliminary efficacy of a family-based cognitive behavioural treatment relative to an active control for youth with suicidal behaviour.Methods 30 youths (93% female; mean (SD) age=14.6 (1.5) years) residing in Sweden with recent suicidal behaviour (last 3 months) and at least one available parent were randomised to 12 weeks of the family-based cognitive behavioural treatment Safe Alternatives for Teens and Youths (SAFETY) or supportive therapy, an active control treatment. Primary endpoint was 3-month post-treatment. Feasibility outcomes included treatment and assessment compliance, adverse events, treatment credibility and treatment satisfaction. Secondary outcomes included suicide attempt, non-suicidal self-injury, anxiety, depression, quality of life and emotion dysregulation.Findings Both treatments showed high compliance, satisfaction, credibility and session completion, with few adverse events and dropouts as well as low attrition (7% at primary endpoint). At the primary endpoint, two (14%) participants in SAFETY and four (27%) in supportive therapy had attempted suicide. Non-suicidal self-injury was reduced by 95% (incidence rate ratio=0.05 (95% CI 0.01 to 0.20)) in SAFETY and 69% (incidence rate ratio=0.31 (0.11 to 0.83)) in supportive therapy. Participation in SAFETY, but not in supportive therapy, was associated with moderate-to-large within-group improvements in anxiety and depression (Cohen’s d=0.85 [0.33 to 1.40]), quality of life (d=1.01 [0.48 to 1.56]) and emotion dysregulation (d=1.22 [0.45 to 2.03]).Conclusions The results suggest that SAFETY is feasible and promising for youth with suicidal behaviour.Clinical implications A large randomised controlled trial is warranted to further examine the efficacy of SAFETY.Trial registration number NCT05537623.

Nonsuicidal self-injury (NSSI) often temporally precedes suicide attempts (SA), and SA predicts suicide. The genetic and environmental aetiologies of the transition from NSSI to SA have not been studied. This study aims to investigate whether NSSI reported at age 18 influences the incidence of SA between ages 18 and 24, and to what extent these transitions from NSSI to SA are influenced by shared genetic and environmental factors. Twins born in Sweden were enrolled in this longitudinal population-based twin cohort study. Self-reports of NSSI and SA were collected at ages 18 and 24. The majority of individuals in the analytical sample (N = 3 934) were female (64.9%) and dizygotic twins (65.0%). We found that NSSI reported at age 18 was associated with an increased risk of SA between ages 18 and 24 (Odds Ratio 5.4, 95% CI 3.3–8.7), after adjusting for sex and childhood psychopathology. There was a strong genetic correlation between NSSI reported at age 18 and incidence of SA between ages 18 and 24 (rA=0.8, 95% CI 0.3–1.0). At age 18, the proportion of variance in NSSI explained by genetic factors was 53%, and the remaining variance was explained by non-shared environmental factors (47%). At age 24, genetic factors explained 30% of the variance in SA between ages 18 and 24, largely explained by shared genetic factors (66.6%) with NSSI reported at age 18. We found evidence that NSSI reported at age 18 had a strong genetic correlation with incidence of SA between ages 18 and 24.

BACKGROUND:Despite considerable interest in the consequences of benzodiazepine and benzodiazepine-related Z-drug (BZDR) use, little is known about whether and how initiation of BZDR treatment relates to the development of alcohol- and drug-related problems. AIMS:This study aimed to examine the association of incident BZDR dispensing with subsequent alcohol- and drug-related problems. METHODS:This nationwide register-based study included demographically matched and co-twin control cohorts. Among all Swedish residents aged older than 10 years and BZDR-naïve by 2007, 960,430 BZDR-recipients with incident dispensation in 2007-2019 and without any recorded pre-existing substance-related conditions were identified and matched (1:1) to non-recipients from the general population. Twin BZDR-recipients (n = 12,048) were linked to 12,579 unexposed co-twins. Outcomes included alcohol and drug use disorders, poisoning, deaths, and related suspected criminal offences. Flexible parametric survival models estimated outcome risks across up to 14 years of follow-up. RESULTS:In the demographically matched cohort (60% women, median age at BZDR initiation 51 years), incidence rates in BZDR-recipients and non-recipients (per 1000 person-years) were 5.60 versus 2.79 for alcohol-related and 4.15 versus 1.23 for drug-related problems, respectively. In fully adjusted models, relative risks were increased for alcohol- and drug-related problems (adjusted hazard ratio (95% confidence interval): 1.56 (1.53-1.59) and 2.11 (2.05-2.17), respectively). The risks persisted within the co-twin comparison, different follow-ups, and all additional sensitivity analyses. CONCLUSIONS:BZDR initiation was associated with a small but robust increase in absolute and relative risks of developing alcohol- and drug-related problems. The findings contribute to evidence base for making decisions on BZDR treatment initiation.

In this article, we assessed the performance of several predictive modeling algorithms of suicide attempt resulting in inpatient hospitalization or suicide among youths ages 9 to 18 (N = 34,528) after contact (6-12 months) with a mental-health specialist in Stockholm, Sweden, from 2006 to 2012. Using 209 predictors across domains (e.g., clinical, demographic, family, neighborhood, social) identified from national registers, we applied standard logistic regression, regularized logistic regression, and machine-learning algorithms (i.e., random forests, gradient boosting, support vector machines). Standard logistic regression (area under the receiver operating characteristic curve [AUC] = 0.77, 95% confidence interval [CI] = [0.72, 0.82]) and random-forest models (AUC = 0.80, 95% CI = [0.74, 0.86]) demonstrated the highest AUCs. Sensitivities ranged from 0.33 (support vector machines) to 0.91 (standard logistic regression). Although the study was underpowered to detect a difference between logistic regression and machine-learning algorithms (outcome prevalence = 0.7%), performance metrics were similar across models. Logistic regression is not clearly worse than machine-learning approaches. Ongoing research is needed to examine how prediction models can augment clinical decision-making.

Psychological treatments targeting emotion dysregulation in adolescents are effective in reducing nonsuicidal self-injury (NSSI) but predicting treatment outcome remains difficult. Identifying sub-groups based on repeated measurements of emotion dysregulation pre-treatment may guide personalized treatment recommendations. We used data from a recent trial evaluating internet-delivered emotion regulation therapy for adolescents with NSSI (n = 138). Latent class analysis was used to identify sub-groups based on pre-treatment responses on the 16-item version of the Difficulties in Emotion Regulation Scale. The primary outcome was self-rated NSSI frequency during treatment, and secondary outcome was the proportion of participants with no NSSI 1-month post-treatment. Three sub-groups of emotion dysregulation were identified: Low variability and low mean (Group 1), Low variability and high mean (Group 2), and High variability and low mean (Group 3). Sub-groups did not differ in NSSI frequency during treatment (Group 2 IRR = 1.06 [95% CI 0.49 – 2.29], p = .88; Group 3 IRR = 1.22 [95% CI 0.31 – 4.76], p = .77). However, more participants in Group 1 compared to Group 2 abstained from NSSI at 1-month post-treatment (OR = 3.63 [95% CI 1.16 – 11.33], p = 0.01). Latent class analysis identified sub-groups predictive of NSSI absence post-treatment, demonstrating clinical utility.

Nonsuicidal self-injury is a common health problem in adolescents and associated to future suicidal behavior. Predicting who will benefit from treatment is a critical first step towards personalized treatment approaches. Machine-learning algorithms have been proposed as techniques that might outperform clinicians’ judgment. The aim of this study was to compare clinician and machine-learning algorithm predictions of which patients would abstain from nonsuicidal self-injury (measured using youth version of Deliberate Self-harm Inventory) after an Internet-delivered emotion regulation therapy (n = 138). Both clinician (accuracy = 0.63) and model-based (accuracy = 0.67) predictions achieved significantly better accuracy than a simple all‐respond model (accuracy = 0.49 [95% CI 0.41 to 0.58]), however there was no statistically significant difference between them. Adding clinician predictions to the random forest model did not improve accuracy. Emotion dysregulation was identified as the most important predictor of nonsuicidal self-injury absence. Here we show comparable prediction accuracy between clinicians and a machine-learning algorithm in the psychological treatment of nonsuicidal self-injury in a moderately sized clinical sample among youth. As both prediction approaches achieved modest accuracy, the current results indicate the need for further research to enhance the predictive power of machine-learning algorithms. Screening for emotion dysregulation may be an important factor to consider in the treatment planning of adolescents with nonsuicidal self-injury.