Care Management or Dialectical Skills Training Not Effective at Reducing Risk for Self-Harm

Among young adult outpatients with suicidal ideation, care management or brief dialectical behavior therapy skills training were not effective at reducing risk for self-harm. These findings were published in JAMA.

Between 2015 and 2018, patients with frequent suicidal thoughts were identified via a routine screening for depression using the Patient Health Questionnaire-9 (PHQ-9) at 4 integrated health systems in the United States. Participants (N=18,882) were randomized to receive care management with systematic outreach and care (n=6230), online dialectical behavior therapy skills training in mindfulness, mindfulness of current emotion, opposite action, and paced breathing (n=6227), or usual care (n=6187) for up to 12 months. Self-harm events and mortality were assessed during an 18-month follow-up.

The patients were 67% women, 48% were aged ≥45 years, and 50% were recruited at mental health specialty clinics.

Self-harm occurred among 540 participants, including 45 self-harm-related deaths. The event rate was 3.27% among the care management, 3.92% among the skills training, and 3.10% among the usual care cohorts.

Compared with usual care, the patients who received the care management were not at increased risk for self-harm (hazard ratio [HR], 1.07; 95% CI, 0.84-1.37; P =.52) and recipients of the skills training were at risk (HR, 1.29; 95% CI, 1.02-1.64; P =.015). Similar results were observed when patients were stratified by baseline PHQ-9 score.

When stratifying by self-harm events leading to death or hospitalization, no difference was observed between usual care and care management (HR, 1.03; 95% CI, 0.71-1.51; P =.84), and those offering the skills training tended to have increased risk (HR, 1.34; 95% CI, 0.94-1.91; P =.07). Similar results were observed when stratifying by self-harm events that were flagged as unintentional or with undetermined intent.

The investigators observed that risk for self-harm varied significantly on the basis of intervention participation among the care management (P =.002) and skills training (P <.001) cohorts.

This study was limited by the fact that self-harm events that did not result in health care consultation were not included.

“Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce the risk of self-harm, and offering brief online training in selected dialectical behavior therapy skills training increased the risk of self-harm, compared with usual care. These findings do not support implementing the approaches in this study,” concluded the study authors.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Simon GE, Shortreed SM, Rossom RC, et al. Effect of offering care management or online dialectical behavior therapy skills training vs usual care on self-harm among adult outpatients with suicidal ideation: a randomized clinical trial. JAMA. 2022;327(7):630-638. doi:10.1001/jama.2022.0423