The Course of Self-Injury in Help-Seeking Adolescents: Treatment, Trajectory, and Prediction of a Transdiagnostic Phenomenon

Nonsuicidal (NSSI) and suicidal self-injurious behaviors (SB) are common in adolescence. They occur in the general public but are particularly prevalent in psychiatric populations. The recognition of NSSI and SB as clinically relevant transdiagnostic phenomena has led to significant growth in scientific literature. However, profound knowledge regarding the courses and specific predictors is still scarce. The aim of the present dissertation is to address critical research questions with a focus on longitudinal analyses in a high-risk population of help-seeking adolescents. In the first study, the long-term effects of a brief intervention for adolescents with NSSI were examined. In a period of two to four years after the initial treatment phase, incidents of NSSI and SB reduced further, as did depression and borderline personality disorder criteria. Many patients received additional psychotherapy during the follow-up period which further decreased the frequency of NSSI. The focus of the second study was on the trajectory of NSSI over one year. An individualized analytical approach revealed that 75% of participants reduced the frequency of NSSI by at least half and 25% stopped NSSI completely. One in ten adolescents deteriorated over time and relapses were common. Predictors of change included depression, baseline NSSI frequency and the duration of inpatient treatment. The third publication analyzed the predictive value of self-rated risk for suicide attempts. Out of several clinically feasible variables, self-rated risk was the best predictor of actual suicide attempts. Depressive symptoms moderated the effect such that higher depression severity was linked to less accurate self-ratings. Suicidal and nonsuicidal self-injurious behaviors are complex and highly heterogeneous phenomena. Overall, the results reported in this dissertation provide important insight into the trajectory, treatment, and prediction of NSSI and SB in at-risk youth. Sophisticated longitudinal analyses with a focus on individual paths and alternative data sources have the potential to improve the current understanding of NSSI and SB and provide crucial knowledge for clinicians

Adolescent mental health problems in early stages of the COVID-19 pandemic were masked by lockdown measures and restrictions.

In the BJPsych Open Wong et al examined the influence of lockdown stringency during early stages of the COVID-19 pandemic on psychiatric emergency presentations among children and adolescents from ten countries. Data from March and April 2019 were compared with the same time frame in 2020, with particular focus on self-harm admissions. In this editorial, the publication is summarised and potential implications for the field and future studies are discussed

Evaluation of a guided internet-based self-help intervention for older adults after spousal bereavement or separation/divorce: A randomised controlled trial

Background: While several internet interventions target severe prolonged grief symptoms after bereavement, no randomised controlled trial investigated interventions for prolonged grief after separation/divorce. Methods: This randomised controlled trial aimed to evaluate the efficacy of a guided internet-based self-help intervention for prolonged grief symptoms after spousal bereavement or separation/divorce compared to a wait- list control group. Furthermore, we analysed whether the intervention was also efficacious for participants with milder grief symptoms. Results: A total of 110 participants were mainly recruited by newspaper articles. Average age was 51 years, 77% were separated/divorced, 79% were female. Dropout rate was 11%. Compared to the control group, the inter- vention resulted in significant reductions in grief (d = 0.81), depression (d = 0.59), psychopathological distress (d=0.39) (primary outcomes), embitterment (d=0.37), loneliness (d=0.37) and an increase in life sa- tisfaction (d = −0.41) (secondary outcomes). These gains were maintained over three months. Improvements were similar among widowed and separated/divorced participants as well as among participants with low, medium or high levels of grief at baseline. Limitations: Limitations include the self-selective sample and a rather small number of widowed participants. Conclusions: Findings indicate that an internet intervention based on models for coping with grief after be- reavement was not only beneficial for widowed but also separated or divorced participants. Furthermore, also participants with lower levels of grief at baseline benefitted from the intervention. This corroborates that in- dicated prevention efforts for grief are efficacious

Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury.

BACKGROUND Nonsuicidal self-injury (NSSI) is prevalent in adolescent clinical samples. There is evidence that NSSI can be treated effectively but data on individual treatment outcomes is limited. The goal of this study was to examine response, remission, exacerbation, and relapse rates over one and two years, respectively, among a clinical sample of adolescents with NSSI. Furthermore, we aimed to identify clinically relevant predictors of NSSI trajectories. METHODS The sample consists of n = 203 adolescents (12-17 y., 94% female) from a specialized outpatient clinic for risk-taking and self-harming behavior with NSSI on at least five days in the six months before first assessment. Assessments were completed at baseline and one (FU1) and two (FU2) years later using structured clinical interviews and self-report questionnaires. RESULTS At FU1, 75% reported a reduction in NSSI frequency by at least 50% (treatment response); among those, one third (25% of the entire sample) achieved a remission (0 NSSI); an exacerbation (⩾50% more NSSI) was observed in 11% of patients. Of those in remission, 41% relapsed one year later. Predictors of non-response or non-remission were inpatient treatment and depressive symptoms. Adolescents with lower NSSI frequency at baseline had a higher risk of exacerbation. Due to limited sample size at FU2 no prediction model for relapse was established. CONCLUSIONS While most adolescents presenting with NSSI achieved significant improvement, more attention should be paid to the rather low rates of full remission. Prediction and early detection of individuals who deteriorate during or relapse after treatment is critical

Self-rated risk as a predictor of suicide attempts among high-risk adolescents

Background: Predicting suicide attempts is a challenging task for clinicians and researchers, particularly among high-risk individuals (i.e. adolescents with lifetime suicide attempts). In this study, we examined whether adolescents were able to predict their own risk of attempting suicide in the future and whether borderline personality disorder (BPD) or depressive symptoms impacted the predictive value of self-ratings. Methods: Structured clinical assessments were conducted at baseline and after 12 months in a high-risk sample of treatment-seeking adolescents (n = 134; 12-17y.; 90% female) with at least one lifetime suicide attempt. Results: During the follow-up period, n = 51 participants (38%) attempted suicide at least once. Self-rated risk was a significant predictor for the recurrence of a suicide attempt, whereas BPD and depression were not. While there was no significant interaction between self-rated risk and BPD, a negative interaction emerged between self-rated risk and depression in the prediction of a suicide attempt. Greater depression severity diminished the predictive value of self-ratings. Limitations: Depression severity was measured using a questionnaire, not a clinical interview. The findings may not be applicable to less burdened samples. Conclusions: Asking high-risk adolescents to rate their own risk of attempting suicide appears to be an easy to apply method in improving the prediction of future suicide attempts in the clinical context

Hepatitis delta infection among persons living with HIV in Europe

BACKGROUND AND AIMS A high prevalence of hepatitis delta virus (HDV) infection, the most severe form of viral hepatitis, has been reported among persons living with HIV (PLWH) in Europe. We analysed data from a large HIV cohort collaboration to characterize HDV epidemiological trends across Europe, as well as its impact on clinical outcomes. METHODS All PLWH with a positive hepatitis B surface antigen (HBsAg) in the Swiss HIV Cohort Study and EuroSIDA between 1988 and 2019 were tested for anti-HDV antibodies and, if positive, for HDV RNA. Demographic and clinical characteristics at initiation of antiretroviral therapy were compared between HDV-positive and HDV-negative individuals using descriptive statistics. The associations between HDV infection and overall mortality, liver-related mortality as well as hepatocellular carcinoma (HCC) were assessed using cumulative incidence plots and cause-specific multivariable Cox regression. RESULTS Of 2793 HBsAg-positive participants, 1556 (56%) had stored serum available and were included. The prevalence of HDV coinfection was 15.2% (237/1556, 95% confidence interval [CI]: 13.5%-17.1%) and 66% (132/200) of HDV-positive individuals had active HDV replication. Among persons who inject drugs (PWID), the prevalence of HDV coinfection was 50.5% (182/360, 95% CI: 45.3%-55.7%), with similar estimates across Europe, compared to 4.7% (52/1109, 95% CI: 3.5%-5.9%) among other participants. During a median follow-up of 10.8 years (interquartile range 5.6-17.8), 82 (34.6%) HDV-positive and 265 (20.1%) HDV-negative individuals died. 41.5% (34/82) of deaths were liver-related in HDV-positive individuals compared to 17.7% (47/265) in HDV-negative individuals. HDV infection was associated with overall mortality (adjusted hazard ratio 1.6; 95% CI 1.2-2.1), liver-related death (2.9, 1.6-5.0) and HCC (6.3, 2.5-16.0). CONCLUSION We found a very high prevalence of hepatitis delta among PWID across Europe. Among PLWH who do not inject drugs, the prevalence was similar to that reported from populations without HIV. HDV coinfection was associated with liver-related mortality and HCC incidence

Hepatitis delta infection among persons living with HIV in Europe

Background and aims: A high prevalence of hepatitis delta virus (HDV) infection, the most severe form of viral hepatitis, has been reported among persons living with HIV (PLWH) in Europe. We analysed data from a large HIV cohort collaboration to characterize HDV epidemiological trends across Europe, as well as its impact on clinical outcomes. Methods: All PLWH with a positive hepatitis B surface antigen (HBsAg) in the Swiss HIV Cohort Study and EuroSIDA between 1988 and 2019 were tested for anti-HDV antibodies and, if positive, for HDV RNA. Demographic and clinical characteristics at initiation of antiretroviral therapy were compared between HDV-positive and HDV-negative individuals using descriptive statistics. The associations between HDV infection and overall mortality, liver-related mortality as well as hepatocellular carcinoma (HCC) were assessed using cumulative incidence plots and cause-specific multivariable Cox regression. Results: Of 2793 HBsAg-positive participants, 1556 (56%) had stored serum available and were included. The prevalence of HDV coinfection was 15.2% (237/1556, 95% confidence interval [CI]: 13.5%-17.1%) and 66% (132/200) of HDV-positive individuals had active HDV replication. Among persons who inject drugs (PWID), the prevalence of HDV coinfection was 50.5% (182/360, 95% CI: 45.3%-55.7%), with similar estimates across Europe, compared to 4.7% (52/1109, 95% CI: 3.5%-5.9%) among other participants. During a median follow-up of 10.8 years (interquartile range 5.6-17.8), 82 (34.6%) HDV-positive and 265 (20.1%) HDV-negative individuals died. 41.5% (34/82) of deaths were liver-related in HDV-positive individuals compared to 17.7% (47/265) in HDV-negative individuals. HDV infection was associated with overall mortality (adjusted hazard ratio 1.6; 95% CI 1.2-2.1), liver-related death (2.9, 1.6-5.0) and HCC (6.3, 2.5-16.0). Conclusion: We found a very high prevalence of hepatitis delta among PWID across Europe. Among PLWH who do not inject drugs, the prevalence was similar to that reported from populations without HIV. HDV coinfection was associated with liver-related mortality and HCC incidence

Long-term quantitative hepatitis B surface antigen (HBsAg) trajectories in persons with and without HBsAg loss on tenofovir-containing antiretroviral therapy

OBJECTIVES Improving the understanding of the patterns of quantitative hepatitis B surface antigen (qHBsAg) trajectories associated with HBsAg loss is important in light of novel anti-hepatitis B virus agents being developed. We evaluated long-term qHBsAg trajectories in persons with HIV and HBV during tenofovir-containing antiretroviral therapy in the Swiss HIV Cohort Study. METHODS We included 29 participants with and 29 without HBsAg loss, defined as qHBsAg <0.05 IU/mL. We assessed qHBsAg decline during therapy in both groups and used agglomerative hierarchical clustering to identify different qHBsAg trajectory profiles in persons with HBsAg loss. RESULTS The median follow-up time was 11.9 years (IQR 8.4-14.1), and the median time to HBsAg loss was 48 months (IQR 12-96). Among participants with HBsAg loss, 79% had a qHBsAg decline ≥1 log$_{10}$ IU/mL 2 years after starting tenofovir. The trajectories in qHBsAg levels during tenofovir therapy were heterogeneous, characterized by five distinct profiles. Among participants without HBsAg loss, only 7% had a qHBsAg decline ≥1 log$_{10}$ IU/ml after 2 years. CONCLUSIONS Most persons with HIV who experienced HBsAg loss had an early decline in qHBsAg levels, with diverse trajectories during long-term tenofovir therapy. In persons without HBsAg loss, qHBsAg levels remained remarkably stable over time