Exploring Suicidal Ideation in Adolescents with Borderline Personality Disorder

This qualitative study aims to explore the relationship between adolescent patients with Borderline Personality Disorder (BPD) and suicidal ideation. The results indicate that adolescents with BPD experience suicidal ideation earlier and more frequently than clinical controls.

Mental Health Nursing Theory Four
Evidence Based Practice and Complex Mental Health Needs
Word Count: X

This qualitative study has aimed to explore adolescents with Borderline Personality
Disorder (BPD). BPD is a complex psychiatric condition and individuals with this condition
have an unstable and insecure self-image, a dangerous tendency to self-harm, suicidal
behaviours, transient and dissociative symptoms that are intermittent and persistent
(Linehan, 2018). However, the research shows 8 - 10% of those diagnosed with BPD
commit suicide (Anderson, 2016). The study aimed is to investigate the relationship
between adolescent patients with BPD and the characteristics of suicidal ideation, for
example; frequency, period and starting age. This topic is examined using both clinician-
rated and adolescent-rated suicidal ideation, attempts to evaluate, assess qualitative and
numerical BPD. The results of this research indicate that earlier in their lives, adolescents
with BPD experience suicidal ideation, and more frequently than clinical controls. Notably,
the groups ranged not in terms of the adolescent-rated suicidal ideation magnitude or
length, intent to commit suicide.
The authors describe the case reports of a 19 – year - old girl who after a traumatic
childhood, began to deliberately self-harm often by cutting her forearms (Rashid and
Gosai, 2011). The authors mirrored a storey on the National Centre for Biotechnology
Information (NCBI). The authors had the opportunity to visit psychiatric hospital, recovery
college, day centres and other locations where groups of mental health patients meet for
day – to - day activities. Authors work closely with different patients to build trust and the
therapeutic relationship. Therefore, some of them shared their experience on how self-
harm affected their lives with deliberately negative thoughts and how meeting with other
peers with similar stories helps to build their confidence. Accordingly, the authors chose to
do more research.
They examined on what more can be of advantage rather than meeting for
activities, as the authors say that the psychosocial or pharmacological treatment for self-
harm (SH) in adolescents (up to 18 years of age) is not broadly utilised in practice, and the
BPD awareness of mindfulness must be used to classify all randomised controlled trials
(RCTs) of CBT. Moreover, the authors have been inspired as a future mental health
nursing to the attendant to advance non-medical intervention, and that drives the craving
of needing to build knowledge. Hence, the longing was to explore the subject on the
adequacy of care as therapeutic interventions for individuals who are self-harm or suicide
attempts. Venta and colleagues (2012) state that suicide ideation or attempts self-harm is
a significant health issue among young people where recent research has emerged that
borderline personality disorder (BPD) may pose a much greater risk to individuals alone
NT4 - Mental Health Nursing Page | 2

without having depression. However, a few studies have examined the association
between BPD and attempted suicide among younger’s and little is known about the
attribute of suicidal ideation BPD at this time. However, for individuals with distressing self-
harm, there seems to be a prior lack of study or analysis formerly. While conducting the
literature Spirito (2002) found that facilitated therapy groups for continuing distressing self-
harm with healthy study outcomes and there is growing evidence recently. The problems
faced by the author were to find a research paper comparable to the choice of question.
The question formulated by the author was the intervention for young people, who self-
harm (SH), suicide attempt (SA) or suicidal ideation (SI). The subject closing the question
framed for a quantitative research paper was (Cognitive behavioural therapy for suicide
prevention in youth admitted to hospital following an episode of self-harm: A pilot
randomized controlled trial) and for the qualitative paper was (Psychosocial interventions
for self-harm, suicidal ideation and suicide attempt in children and young people).
Therefore, this qualitative study paper was also specifically designed for adolescents who
psychological distress and is considered one of the criteria for suicidal death that the
author reflects on.
However, the qualitative research on Short Cognitive Behavioural Therapy (BCBT)
for suicide prevention versus an attentional control group (minimally-directive supportive
psychotherapy) for adolescents hospitalised after SH examined (aged 16–26). Both
treatments involved ten acute 15-week cycles and three booster sessions taking effect at
three-month periods afterwards. The primary effectiveness result was more than 70%
retention at the endpoint of the analysis.
Though, it has been CBT's pros and cons. Cognitive Behavioural Therapy focused
on the biopsychosocial perspective of emotional reaction, such as feelings and behaviours
arising from patient thoughts, according to the Nationwide Association of Cognitive-
Behavioural Therapists. CBT, unlike its psychodynamic counterparts, is a goal-oriented
and problem-focused treatment. As a method, Cognitive Behavioural Therapy emphasises
on the present, rather than on a comprehensive examination of the developmental history.
A pilot randomised controlled study suggested that Trauma-Focused Cognitive-
Behavioural Treatment (TF-CBT) has numerous benefits for youth, such as devastating
occurrence CBT, which aims to reduce both emotional and behavioural symptoms
stemming from traumatic stress.
Research has found that Cognitive Behavioural Therapy can be as successful as
medicine in the treatment of self-harm and other psychological issues. CBT usually
completed over a brief period like other talking therapy. However, to benefit from Cognitive
NT4 - Mental Health Nursing Page | 3

Behavioural Therapy, individuals need to dedicate themselves to the process. However,
they maintain the quality of Cognitive Behavioural Therapy; it may not be suitable for
people with more complex mental health needs or physical disabilities. As CBT can
include expressing their emotions and negative feelings, individuals may perceive initial
times where they feel more nervous or emotionally insecure. Other challenges might be
other terms that had been used primarily in quantitative paper, such as schizophrenia,
cognitive behavioural therapy for psychosis (CBTp), which contradicted the question
formulated. While constructing a research question, method of 'Population, Exposure and
Outcome (PEO) or Population Intervention, Comparison and Outcome (PICO)' is the
standard framework for planning the clinical question, particularly patients relating to the
effectiveness of (intervention) therapies and for identifying keywords of the search for
disorder emerging from the concern of a patient or population. Therefore, mainly used in
medical fields to support medical practitioners improve and recognise main terms that
make it simpler to look for evidence. (Stern, Jordan, and McArthur, 2014). These models
often concentrate on how to analyse the literature database and not just on science .
(Oermann, and Hays, 2015). The author used PEO framework to evaluate whether a pre-
existing disorder or exposure is likely to occur in or in progress from a specific diagnosis.
See Table 1, for main terms and the corresponding synonyms and then using the relevant
mental models of Boolean concepts (Goodwin and Johnson-Laird, 2011, p.34)
Table 1. Research theme utilising the PEO framework:
P Population Adolescents / young adults
experiencing self-harm (SH)
E Exposure Borderline Personality Disorder
(BPD) or psychological distress
or emotion dysregulation
O Outcome Preliminary effectiveness
success of Brief Cognitive
Behavioural Therapy (BCBT) for
suicide prevention or Dialectical
Behavioural Therapy (DBT)
NT4 - Mental Health Nursing Page | 4

The PEO designed inclusion and exclusion criteria to support the accuracy of the
questionnaire collected in practice, for example; the inclusion criteria set limitations for the
researcher to specifying what theoretically included, entirely irrelevant to the subject or
component of the participation qualifications (Stern, Jordan and McArthur, 2014). Also,
inclusion models help minimise the specific inclinations of the reviewer, ensuring what
reports are selected independently from analysts relevant, bound into a biased framework
or align emerging outcomes on the predefined, rational criteria (Aromataris and Pearson,
2014).
The inclusion criteria typically comprise angles such as the method of analysis, type
of information (qualitative or quantitative), the phenomenon under review, year of research
or group of participants (Stern and colleagues, 2014). While exclusion serves as a tactic to
avoid much less optimised results and seeks to eliminate prejudice, for example; excluding
papers dependent on language bias may introduce into the survey, restricting the
adaptability of the outcomes (Geerligs et al., p36, 2018).
Nonetheless, this might be strenuous to avoid as translating articles is frequently
unrealistic. Whatever the inclusion criteria, they should be legitimate and adequately
documented in a protocol depending on the prerequisites of the sample. Kallio et al. (2016)
point out that inclusion and exclusion requirements are often crucial to their reflection on
the qualitative data of outcomes. The researchers establish criteria to decide whether a
person is eligible as a member of the population or excluded. Table 2 outlines the inclusion
criteria used by the hypothetical question and indicates the methodological forms of
justification used in a quantitative systematic review protocol.
NT4 - Mental Health Nursing Page | 5

Table 2. Criteria for inclusion and exclusion:
INCLUSION EXCLUSION
Primary research study Secondary research study
By peer reviewed /academic journal are
used in the study for gathering data on
the topic.
Unclassified theoretical or non-academic
research on BPD awareness of mindfulness
is excluded.
2020 onwards Pre - 2020
Groups - Adolescents/Youth/Young
Adults
Adults / included children under the age of 12
years
Journals Articles - Journal of Affective
Disorders
Textbooks
Brief Cognitive Behavioral Therapy
(BCBT), Dialectial Behavioral Therapy
(DBT), or Minimally-Directive Supportive
Psychotherapy (Control)
Antidepressants, Antipsychotics or Mood
Stabilisers (including antiepileptics)
medications
A pilot randomized controlled trial (RCT) Meta-Analyses (MAs) to combine the
outcomes of multiple scientific studies is not
included.
NT4 - Mental Health Nursing Page | 6

Nurse’s position has essentially progressed in the 21st century. Nursing research
conveys an awareness of the nursing practice and its impacts on patients much like
everyone’s in communities. The upheld scientists at the National Institute of Nursing
Research (NINR) explore and approaching nursing research as critical to the nursing
profession and is necessary for proceeding with progressions that facilitates optimal
nursing care (Tingen et al., 2009). Nurses work in a diversity of settings, including the
hospital or the community health setting. While each position conveys various
responsibilities, the essential objective of a professional nurses remains the same, to
support the patients and offer optimum treatment based on evidence gained through the
observation. Hence, nursing research is imperative to the practice of professional nursing,
and the significance of their inclusion cannot be overemphasised during undergraduate
guidance (Fain, 2020).
First-hand, the author, included primary research and excluded secondary research
because primary research uses more resources than secondary research (usually more
time-consuming). Author’s best interests are primary research after the gaps in available
secondary research have established. However, it is a calculable and proven method of
practical analysis, relying on the information gathered, and help nurses to create strategies
and solve problems based on the knowledge they accrue (McCrocklin, 2020). For
example, collected the data, surveying a specific population, developed and performed an
experiment, conducting a focus group, observing a particular population/task, primary
research provided the growing emphasis on evidence-based nursing practice in the
Western world (Sullivan, 2013). The author excluded textbooks which take longer to
publish and include journals which are a formulated source of the latest information on
nearly all subjects as well as the latest study results and preferred mode of communication
(Wood & Haber, 2018).
Looking for theoretical, research or clinical articles, the author prioritised peer
reviewed academic journals. In addition, (Haber & Wood) for possible publication, there is
a board of internal and external inspectors who submits manuscripts and ensure it’s
unbiased. Though peer review has been weighed as not constantly being an effective,
however it gives the readers assurance that it meets satisfactory standards of scholarship
discussing reliability and authenticity on an author’s work (Mateo & foreman, 2014).
NT4 - Mental Health Nursing Page | 7

The author used the bibliographic reference of the Cumulative Index for Nursing
and Allied Health Literature (CINAHL), which offers indexing for over 3,000 nursing, allied
health, scientific and consumer health journals. Some databases are considered more
useful than others for specific types of review, and CINAHL is generally considered a
successful source to search when conducting qualitative research (Murphy and Cowman,
2008, p.75).
Two case studies investigated CINAHL’s performance. One study by Subirana et al.
(2005) felt it necessary to search both CINAHL and MEDLINE to identify all related studies
included in a systematic review covering a nursing subject. The author suggests that
CINAHL could be a better option for qualitative analysis studies than MEDLINE because it
covers a broad spectrum of cases in the literature, biomedicine, health sciences
databases, and 17 associated health disciplines (Alpi, 2006). Also, found some evidence
that CINAHL includes specific research for systematic reviews and verify all the databases
which originated from the study.
The general objective was to locate the one with the highest published articles by
the research question. CINAHL, therefore, used to search for keywords by combining
terms using “OR”, author goal was to achieve search techniques of 100% sensitivity and
100% accuracy, and by using “AND”, to achieve at least 50% specificity (Tanon el at.,
2010). Research conducted on patients with a range of long-term conditions shows the
main expectations affecting critical thinking assessments of a pharmaceutical drug.
However, patients can group into two categories, for example; perception of personal
treatment needs (Necessity Expectations) and a range of possible adverse effects. This
‘Necessity-Concerns Framework (NCF)’ will provide clinicians with a convenient model to
elicit and address core principles supporting patients’ behaviours and care decisions
(Horne et al., 2013). Based on this study, CINAHL has the best coverage of literature
beyond nursing articles, the most extensive access to biomedical titles and the highest
accessibility for nursing practice, including allied health literature (Jacobs and Levy, 2006).
It also has hundreds of full-text publications identified in the broader volume of records
dating back to 1937 and expanded content (Oermann and Hays, 2015). See Table 3 below
for further information.
Table 3. Results from the search:
Search No. Search Words Results From
CINAHL
S1 Adolescents* OR Youth* OR Young Adults 383,301
NT4 - Mental Health Nursing Page | 8

S2 Self-harm* OR Suicide Attempt* OR Suicide
Death* OR Suicidal Ideation* OR Suicidal
Thoughts/Behaviour* OR Non-Suicidal Self-Injury
23,237
S3 Brief Cognitive Behavioural Therapy* OR
Cognitive Behavioural Therapy* OR Minimally-
Directive Supportive Psychotherapy* OR
Dialectical Behavioural Therapy* OR Emotion
Regulation Group Therapy* OR Family Therapy*
OR Brief Contact Interventions
22,578
S4 Primary Feasibility Outcomes* OR Preliminary
Effectiveness* OR Benefits* OR Effects* OR
Impact* OR Efficacy Measures
1,398,506
S5 S1 AND S2 AND S3 AND S4 To be
complete
Database search
limits used The data older than 2017 is not included
To be
complete
By date < 10 years
old 2020, 2017
To be
complete
By peer reviewed
academic journal
type
PUBMED, ELSEVIER
To be
complete
By full text,
language/geography
(or any other
database filter)
Date, country/ region, values,
To be
complete
Table 4. Qualitative Summary Table:
Qualitative Paper
NT4 - Mental Health Nursing Page | 9

Cox, G. and Hetrick, S.
2017
Victoria, Australia
Author
Date
Country of Origin
Aims To identify evidence for the effectiveness of individual
psychosocial interventions on suicide-related behaviours
(SRBs) in children and adolescents up to 25 years of age,
and to facilitate a holistic approach with particular emphasis
on form setting of the intervention, as well as the method of
delivery to suicide reduction.
Methodology To find systematic reviews (SRs) or meta-analyses (MAs)
conducted within the context of an SR. SRs is comprising
published or continuing randomised controlled trials (RCTs) of
individual therapeutic interventions delivered to children or
adolescents up to age 25 years who had experienced SH, SI
or SA. SRs included trials where the primary or secondary
outcome was SRB or incidence suicide.
Data Collection The U.S. clinical data group survey reveals that 24% of young
people between the age of 12 and 17 have SI over the past
12 months and that between 10 and 17% have SA. However,
in psychiatric specimens, this incidence is more significant,
with up to 85% of young people who already have suicidal
symptoms showing SI. Moreover, 32% of clinically referred
children and teenagers are SA, and 2.5% and 7% are dying
from adult suicide.
Population and Sample Four SRs has fulfilled the criteria for this review; it was agreed
that all four of them were worthy of inclusion and exploration
within this review because of variations of inclusion criteria,
qualitative techniques, and the database searched. One of
these SRs provided psychosocial interventions for adolescent
suicide across a range of settings which included RCTs
promoting standardized, selective and suggestive groups.
Two SRs focused on youths who had been submitted to
psychiatric care by SH or SRBs, including active SI, and the
other SR, it focused on web-based and digital psychosocial
suicide intervention for adolescents. Three of the studies
NT4 - Mental Health Nursing Page | 10

involved trials for young people between the ages of 12 and
25 years, and one included trial with participants up to the
age of 18 years. This review describes sixteen individual
practices from these four SRs. A Shand et al. (2013) included
as a Perry et al. (2016)'s unpublished trial in the SR was
significant as this review was prepared, this has therefore
already been published, and the total age of participants is
26.25% for a variety of ages of up to 61 years and are thus
excluded.
Data Analysis Strategy Alavi et al. (2013) used a waitlist analogy to test a Cognitive
Behavioural Therapy protocol developed primarily to address
SRBs based on the Stanley model. The main components in
these involve chain analysis (examination in circumstances,
problem-solving training, cognitive restructuring,
psychological management, distress tolerance strategies and
problem-solving to resolve the processes that sustained SH,
emotions and behaviour occurred before and at the moment
of the SA), safety planning, psycho-education, development
of motivations for living and hopes, therapy and cognitive
therapy, mood monitoring, psychotherapy for psychosis and
distress tolerance strategies, physical pain, stress
management, self-esteem, research and social assistance
skills training. Parents were required to participate in the first
session and, if necessary, 'standard psychiatric treatment'
was used for medication given to all groups. Slee et al. 2008
have implemented a CBT protocol directly addressed to SH
but created the protocol themselves where parents were
invited to act as supporters.
Key Findings The comparison group obtained sources of support interview,
and both groups received whatever support in the community.
For example; Two trials have used green cards or postcards
to deliver their interventions, which did not involve any
ongoing therapist contact. One trial assessed the
effectiveness as a form of proximal support method to
adolescents who had been admitted to the hospital for an
episode of SH was issued a token (referred to as a green
NT4 - Mental Health Nursing Page | 11

card). They use it to readmit to the hospital facility. The goal
of the green card was to offer an alternative route for
adolescents to exit to get support from their situation. Another
trial used postcards that were delivered to participants every
month that included individual support outlets (identified in an
initial 'sources of help interview' where young people were
questioned what they find helpful in moments of distress,
such as listening to music or chatting to a friend) as well as
evidence-based self-help strategies. The postcards often
inquired for the well-being of the adolescents.
Conclusions Some of the trails listed in this analysis did not consider to be
relevant variations in the outcomes of SI, SA and SH between
groups, whereby the aim is not to perform an MA; it makes it
challenging to suggest specific therapeutic approach over
another. The systematic investigation urgently required in this
field, and given the possible effectiveness of Cognitive
Behavioural Therapy, DBT and MBT in the treatment of SI
and SH in other population groups, these are opportunities
suitable for further research. The face-to-face delivery of
therapy has driven intervention trials until date, the usage of
the internet, social media and technology devices in young
people have provided a unique and modern approach to
suicide reduction. To design and analysis interventions for
young people that can be provided throughout their lifetime
which can be beneficial, as well as implementing smart
technology to assist parents as an alternative to individual
counselling.
Table 5. Quantitative Summary Table:
Quantitative Paper
Sinyor, M. et al
2020
Toronto, Canada
Author
Date
Country of Origin
Aims The first randomised controlled trial investigating group
NT4 - Mental Health Nursing Page | 12

cognitive-behavioural therapy (CBT) for suicide prevention in
youth admitted to hospital following an episode of self-harm
Methodology This single-blind, a pilot randomized controlled trial examined
brief cognitive behavioural therapy (BCBT) for suicide
prevention versus minimally-directive supportive
psychotherapy in adolescents 16–26 years of age
hospitalized after SH. The therapies included ten acute
treatments over 15 weeks with three booster treatments
taking place three months afterwards.
Data Collection Sixty-three patients have been classified as qualifying for the
trial and approached by their most qualified practitioner.
Twenty-four participants were enrolled in the trials over the
18-month recruitment period (September 2016 - February
2018). Mean age, ethnicity, baseline SSI, MADRS, CGI-S or
BDI scores between groups did not vary. Of the 24
participants, 18 were hospitalised after suicide attempts (i.e.,
SH with reported suicidal intent). Table 1 displays group
psychological diagnoses.
Population and Sample Twenty-four patients (12 per group) enrolled with one BCBT
participant, two BCBT controls registered until the first
therapy sessions. Five (45%) of the remaining BCBT
participants and seven (70%) of the treatment groups
attended all ten acute therapy sessions. All participants who
had accomplished five sessions had completed 10.
Significantly, cases of repeating SH were recorded within
BCBT participants (7 of 62 weeks of acute follow-up; 11%)
relative to treatment groups (24 of 79 weeks; 30%). Three
participants, all under supervision, made a total of five
suicidal attempts during the analysis.
Data Analysis Strategy This study utilized an intent-to-treat strategy, with all 24
participants randomized into the trial. Also, used Generalized
Estimating Equations (GEE) simulation, which accounts for
repetitive behaviour and incomplete data from participants.
The autoregressive correlation was chosen, and the
regression evaluated for the key results of the time group was
selected as an in-subject predictor.
NT4 - Mental Health Nursing Page | 13

Key Findings In this study, twenty-four subjects were enrolled (12 subjects
per group) along with one brief cognitive behavioural therapy
subject as well as two controls falling out before the first
session of therapy. Five (45 percent) of the residual brief
cognitive behavioural therapy subjects and seven (70
percent) control subjects finished all the 10 sessions of acute
therapy. All subjects who finished five sessions of therapy
went on to finish 10. Significantly fewer instances were there
of repeat self-harm in brief cognitive behavioural therapy
subjects (7 out of 62 weeks of acute follow-up; 11 percent) in
comparison to control subjects (24 out of 79 weeks; 30
percent) (OR 0.34, 95 percent CI0.13 - 0.92). Three subjects,
in the control condition, made five suicide attempts in total
during the study.
Conclusions This study was unable to accomplish the primary objective of
retention of feasibility for BCBT. The original compliance with
the follow-up estimated completion of the analysis had been
shown. Despite limited numbers, a discovery was also made
a significant decrease in repeat SH in the BCBT group.
However, the finding who needs replication to reduce the
uncertainty in experimental results and stop the variability to
increases. Meanwhile, the significance and the confidence
level which gives greater validity to the findings.
Research methods and methodology tools used by researchers to create a sample,
collect and analyse specific information (Mackenzie and Knipe, 2006).
The data that are produced in qualitative research are words and these words needs
sorting and understanding in order to help make sense of the data collected for the study.
Two published critiquing tools were used to critique the papers, A framework for
critiquing qualitative and quantitative research articles taken from: Holland, K. and Rees,
C. (2010) Nursing: evidence-based-practice-skills. Oxford: Oxford University Press, and
these are included in the (Appendix 1 & 2).
Appendices:
Appendix 1.
NT4 - Mental Health Nursing Page | 14

Paper Title Psychosocial interventions for self-harm, suicidal ideation and
suicide attempt in children and young people: What? How? Who?
and Where?
Paper Reference Cox, G. and Hetrick, S., 2017. Psychosocial interventions for self-
harm, suicidal ideation and suicide attempt in children and young
people: What? How? Who? and Where? Evidence-based mental
health, 20(2), pp.35-40.
Critique Tool
Reference
A framework for critiquing qualitative research articles taken
from:
Holland, K. and Rees, C. (2010) Nursing: evidence-based practice
skills. Oxford: Oxford University Press. Table 7.3
Focus This study focuses on examination reports of the efficacy in
suggested individual psychosocial approaches in the care of
children and adolescent self-harm, suicidal ideation and suicide
attempts, with emphasis on the increasing usage of electronic
methods to provide therapeutic intervention.
Background The researcher reviewed that suicidal ideation (SI), self-harm
(SH), suicide attempt (SA) and deliberate suicide are significant
public health concerns. For example; 1) Suicide rates in this
population have been rising. 2) Suicide is also a leading cause of
death for 15–29-year-olds worldwide. 3) In the 15–19 age group,
suicide rates are estimated at 7.4 per 100,000 individuals, with
rates higher for men than for women. However, the large
percentage of young people who harm themselves do not seek
help, as preventive methods focused on the group are critical.
Aim This study aims were: To identify what young people think should
be achieved to prevent them from feeling harmful to themselves;
to implement the Randomised Controlled Trials (RCTs) of
indicated psychosocial interventions for young people up to the
age of 25 years; to explore differences in ethnicity, ethnic group,
and previous self-harm experiences.
Methodology or
Broach Approach
This research study identified 16 RCTs from four systematic
reviews (SRs) that have investigated the effectiveness of
individual psychosocial interventions for suicide-related
behaviours (SRBs). Substantially, the sample sizes of the trials
were limited and thus lacked control. There were a variety of
NT4 - Mental Health Nursing Page | 15

differences in where young people were recruited from, what kind
of intervention was delivered, and whom in research. The
outcome indicators that have been used different experiments and
follow-up assessment points.
Tool of Data
Collection
Usage of the groups ‘Mrazek and Haggerty’ of universal, selective
and indicated interventions.
- Universal interventions are provided to the general public
or whole groups, not chosen based on increased risk.
- Selective interventions are provided to individuals or
subgroups of the population whose risk of suicide might be
higher than in the general public but without indications or
effects (e.g., young people with depressive symptoms or
substance abuse problems).
- An indicated intervention addresses individual who have
signs and symptoms; a history of SRBs in this situation.
Method of Data
Analysis and
Presentation
The current trial of Robinson et al. (2014) implements Cognitive
Behavioural Therapy, which involves elements primarily based on
SI. Although the specific emphasis on SH was less specifically
expressed in the publication of LifeSPAN therapy by Power et al.
(2003), it is defined as involving collaborative risk assessment and
formulation with an emphasis on the functional analysis of suicidal
ideation. In a specialist early intervention clinic for first-episode
psychosis, young people also received treatment as usual (TAU),
and in this analysis, the comparison group received TAU alone. In
additional, interpersonal psychotherapy (IPT) was tested in one of
the trials in which interpersonal conflict areas, interpersonal
sensitivity and function change and grief have been discussed in
relation to SI.
Sample The sample selected in the study was young people admitted to
emergency department. Epidemiological data from the community
samples in the United States of America depicts that, in the
previous 12 months, around 24 percent of young individuals who
are aged between 12 years and 17 years have experienced
suicidal ideation, and between 10 as well as 17 percent have
involved in a suicide attempt. However, the prevalence is high in
clinical samples, with around 85 percent of young individuals
NT4 - Mental Health Nursing Page | 16

experiencing depressive symptoms also reporting Suicidal
ideation. Generally, the size of sample of trials were small and
therefore, lacked power. Variety of differences were there in
where young individuals were recruited from, by whom across the
studies and what intervention was delivered. The result measures
that were utilized varied across the trials, as well as the follow-up
assessment points, make it challenging in order to draw the
conclusions across trials.
Ethical
Considerations
The National Centre of Excellence for Youth Mental Health
founded and awarded the Ethics Committee, in whereby
participants presented with an information sheet and written
consent before interviews at the inpatient facility where the groups
meet for discussions. The analysis was carried out in accordance
with the accepted ethical principles, anonymity and confidentiality
as a pseudonym has been granted to all participants. This
includes consideration for the dignity, rights, safety and wellbeing
of all those concerned. Therefore, for the report, their names have
been modified.
Main Findings In the 16 trials presented in this study, a green card was given,
and postcards were frequently received for CBT, PST, IPT, public
welfare and proximal support strategies. The CBT method, which
has been more extensively researched in the RCTs, is the most
implemented. Most CBT trials had used a face-to-face technique;
however, one existing trial is delivering Cognitive Behavioural
Therapy over the internet. In two PST trials, one delivered face-to-
face intervention, while the other provided a 35-minute video
recording. Trials introducing compassionate therapy and IPT use
a face-to-face method. Two studies used green cards or
postcards to deliver their interventions, with no ongoing therapy
contact; this represents other mental health fields, such as
depression.
Conclusion and
Recommendations
This study considered the adolescents’ family, friends and school
as the primary sources of support in preventing suicidal
behaviour, and more pertinent than external organisations.
However, it increased the availability of school-based mental
wellbeing activities and increased youth-orientation of supporting
NT4 - Mental Health Nursing Page | 17

facilities was suggested.
Overall Strengths
and Limitations
There are some limitations of the study including the data is
limited for the suicide incidence in those age under 15 years.
Apart from this, limited number of trials have been recruited within
a school setting.
Application to
Practice
Face-to-face therapy delivery has dominated the trials of
intervention therefore far, the utilization of the social media,
mobile devices and internet in young individuals enable for
innovative as well as novel approaches to prevent suicide in
youth. Developing interventions with young individuals, which can
be provided in real time to young individuals, may be suitable, and
utilizing electronic devices in order to backing parents as an aide
to individual therapy with young individuals.
Appendix 2.
Paper Title Cognitive behavioural therapy for suicide prevention in youth
admitted to hospital following an episode of self-harm: A pilot
randomized controlled trial.
Paper Reference Sinyor, M., Williams, M., Mitchell, R., Zaheer, R., Bryan, C.,
Schaffer, A., Westreich, N., Ellis, J., Goldstein, B., Cheung, A.,
Selchen, S., Kiss, A. and Tien, H., 2020. Cognitive behavioural
therapy for suicide prevention in youth admitted to hospital
following an episode of self-harm: A pilot randomized controlled
trial. Journal of Affective Disorders, 266, pp.686-694.
Critique Tool
Reference
A framework for critiquing quantitative research articles taken
from:
Holland, K. and Rees, C. (2010) Nursing: evidence-based practice
skills. Oxford: Oxford University Press. Table 7.2
Focus The focus of the study is to explore cognitive behavioural therapy
for suicide prevention in youths admitted to hospital, following an
episode of self-harm and the analysis of the effectiveness of
BCBT as an intervention. Furthermore, it provides explanations of
therapy performing and evaluating procedures and discusses
NT4 - Mental Health Nursing Page | 18

those factors that could influence the effects of the treatment.
Background The researchers suggest that self-harm (SH) is one of the most
substantial risk factors subsequent suicidal deaths. However,
there are limited data on which interventions are more successful
in treating SH among young people.
Aim The aim was to examine the feasibility, acceptability, and
preliminary effectiveness of the BCBT treatment for patients aged
16-26. At a period of 12 months, the primary finding was retention
and therefore believed that 70% of youth stayed in the study.
Methodology or
Broach Approach
A single-blind, pilot randomised controlled trial examined brief
cognitive-behavioural therapy (BCBT) for suicide reduction vs
minimally-directive supportive psychotherapy in adolescents (16–
26 years of age) hospitalised following SH. The treatments
involved ten acute sessions throughout 15 weeks, with three
booster sessions occurring at three months periods respectively
Tool of Data
Collection
Sixty-three patients have been classified as qualifying for the trial
and approached by their most qualified practitioner. Twenty-four
participants were enrolled in the trials over the 18-month
recruitment period (September 2016 - February 2018). Mean age,
ethnicity, baseline SSI, MADRS, CGI-S or BDI scores between
groups did not vary. Of the 24 participants, 18 were hospitalised
after suicide attempts (i.e., SH with reported suicidal intent). Table
1 displays group psychological diagnoses. Table 2 displays the
basic demographic and therapeutic features of participants.
Method of Data
Analysis and
Presentation
Analysis methods of Cox's regression and Kaplan Meier success
was to assess the likelihood of dropout rates and repeat self-harm
within the two groups. The data characteristics within groups were
compared using one-way Analysis of Variance (ANOVA) and two-
sided chi-square tests. Both analyses were conducted using IBM
SPSS Statistics 24 (SPSS Inc., Chicago, IL). According to the
exploratory quality of this pilot analysis, no methodological
adjustment has been provided for different comparisons.
Sample Two sessions randomly selected for the test of fidelity testing per
subject (e.g. except the course dropped before two sessions
concluded). However, in two cases, the sessions in the BCBT
group were unexpectedly stopped at the request of the participant
NT4 - Mental Health Nursing Page | 19

were excluded from the evaluation of fidelity, provided that the
therapist did not have time to complete all the required elements.
Fidelity was 92% with a total of 11.5 Directive Statements in the
BCBT arm and 99% with an average of 1.5 Directive Statements
in the minimally-directive supportive intervention arm. In addition,
one post-baseline visits are made to 21 of the 24 participants
enrolled one BCBT arm participant and two participants in the
control group dropped out following randomization). Five out of 11
did not fulfil the recommended feasibility criteria for acute
treatment, participants (45%) all ten sessions are completed,
seven out of ten participants (70%) completed ten sessions in the
control group. The ratio of risks for dropout in the BCBT group
was not statistically, no arm achieved feasibility over the 12-month
duration of the study (BCBT: one participant, 9%; Control group:
four participants, 40%).
Ethical
Considerations
The study was performed at Sunnybrook Health Sciences Centre,
a large academic hospital in Toronto, Canada, affiliated to a
university. It was approved by the Sunnybrook Health Sciences
Centre's Research Ethics Council, and all participants have given
written informed consent. Details of the approval procedure and
safety control are given in the supplementary file. The psychiatric
hospital unit recruited these subjects. (the latter assesses youth
with SH in medical units).
Main Findings In this study, twenty-four subjects were enrolled (12 subjects per
group) along with one brief cognitive behavioural therapy subject
as well as two controls falling out before the first session of
therapy. Five (45 percent) of the residual brief cognitive
behavioural therapy subjects and seven (70 percent) control
subjects finished all the 10 sessions of acute therapy. All subjects
who finished five sessions of therapy went on to finish 10.
Significantly fewer instances were there of repeat self-harm in
brief cognitive behavioural therapy subjects (7 out of 62 weeks of
acute follow-up; 11 percent) in comparison to control subjects (24
out of 79 weeks; 30 percent) (OR 0.34, 95 percent CI0.13 - 0.92).
Three subjects, in the control condition, made five suicide
attempts in total during the study.
NT4 - Mental Health Nursing Page | 20

Conclusion and
Recommendations
This study failed to accomplish its primary feasibility retention
objective for BCBT. Yet, it did reveal that preliminary adherence to
follow-up predicted completion of study. In spite of small numbers,
the study also found a substantial decrease in repeat self-harm in
the brief cognitive behavioural therapy group, an outcome which
requires replication. If replicated, the outcomes suggested that
brief cognitive behavioural therapy may be an assistive
intervention for youth hospitalized following self-harm.
Overall Strengths
and Limitations
The limitation of the study is that it had modest sample size as
well as retention rate. Apart from the limitation, there is a strength
of article. The intervention used in the study is helpful for youth
hospitalized following self-harm.
Application to
Practice
Repeat self-harm happened during only 11 percent of acute
follow-up weeks in the brief cognitive behavioural therapy group in
comparison to 30 percent of weeks in controls.
NT4 - Mental Health Nursing Page | 21

REFERENCES
McAndrew, S. and Warne, T., 2014. Hearing the voices of young people who self-harm:
Implications for service providers. International Journal of Mental Health Nursing,
23(6), pp.570-579.
Chadwick, P. and Birchwood, M., 1994. The omnipotence of voices. British journal of
Psychiatry, 164(2), pp.190-201.
Rashid, M. and Gosai, I., 2011. The girl who swallows knives: uncontrollable deliberate
self-harm in a teenage girl with borderline personality disorder. Case Reports,
2011(jan20 1), pp.bcr0720103136-bcr0720103136.
Venta, A., Ross, E., Schatte, D. and Sharp, C., 2012. Suicide ideation and attempts
among inpatient adolescents with borderline personality disorder: Frequency,
intensity and age of onset. Personality and Mental Health, 6(4), pp.340-351.
Anderson, R., 2016. Borderline Personality Disorder (BPD). Hauppauge: Nova Science
Publishers, Inc.
Spirito, A., 2002. Group treatment plus usual care decreased the risk of deliberate self-
harm in adolescents who repeatedly harm themselves. Evidence-Based Mental
Health, 5(2), pp.55-55.
1ST Paper Quantitative - Sinyor, M., Williams, M., Mitchell, R., Zaheer, R., Bryan, C.,
Schaffer, A., Westreich, N., Ellis, J., Goldstein, B., Cheung, A., Selchen, S., Kiss, A.
and Tien, H., 2020. Cognitive behavioral therapy for suicide prevention in youth
admitted to hospital following an episode of self-harm: A pilot randomized controlled
trial. Journal of Affective Disorders, 266, pp.686-694.
2nd Paper Qualitative - Cox, G. and Hetrick, S., 2017. Psychosocial interventions for self-
harm, suicidal ideation and suicide attempt in children and young people: What?
How? Who? and Where? Evidence-based mental health, 20(2), pp.35-40.
Goodwin, G.P. and Johnson-Laird, P.N., 2011. Mental models of Boolean concepts.
Cognitive psychology, 63(1), pp.34-59.
Stern, C., Jordan, Z. and McArthur, A., 2014. Developing the review question and inclusion
criteria. AJN The American Journal of Nursing, 114(4), pp.53-56.
Aromataris, E. and Pearson, A., 2014. The systematic review: an overview. AJN The
American Journal of Nursing, 114(3), pp.53-58.
Aromataris, E. and Riitano, D., 2014. Constructing a search strategy and searching for
evidence. American Journal of Nursing, 114(5), pp.49-56.
NT4 - Mental Health Nursing Page | 22

Geerligs, L., Rankin, N.M., Shepherd, H.L. and Butow, P., 2018. Hospital-based
interventions: a systematic review of staff-reported barriers and facilitators to
implementation processes. Implementation Science, 13(1), p.36.
Linehan, M.M., 2018. Cognitive-behavioral treatment of borderline personality disorder.
Guilford Publications.
Fain, J.A., 2020. Reading, understanding, and applying nursing research. FA Davis.
Tingen, M., Burnett, A., Murchison, R. and Zhu, H., 2009. The Importance of Nursing
Research. Journal of Nursing Education, 48(3), pp.167-170.
Sullivan, P., 1998. Developing evidence-based care in mental health nursing. Nursing
Standard (through 2013), 12(31), p.35.
McCrocklin, S., 2020. Primary Vs. Secondary Research - Geopoll. GeoPoll. Retrieved
from: <https://www.geopoll.com/blog/primary-vs-secondary-research/> [Accessed
16 October 2020].
Murphy, P. and Cowman, S., 2008. Accessing the nursing research literature. Nursing
Research: Designs and Methods, p.75.
Subirana, M., Solá, I., Garcia, J.M., Gich, I. and Urrútia, G., 2005. A nursing qualitative
systematic review required MEDLINE and CINAHL for study identification. Journal
of Clinical Epidemiology, 58(1), pp.20-25.
Alpi, K.M., 2006. Mapping the literature of emergency nursing. Journal of the Medical
Library Association: JMLA, 94(2 Suppl), p.E107.
Horne, R., Chapman, S.C., Parham, R., Freemantle, N., Forbes, A. and Cooper, V., 2013.
Understanding patients’ adherence-related beliefs about medicines prescribed for
long-term conditions: a meta-analytic review of the Necessity-Concerns Framework.
PloS one, 8(12), p.e80633.
Tanon, A.A., Champagne, F., Contandriopoulos, A., Pomey, M., Vadeboncoeur, A. &
Nguyen, H. 2010, "Patient safety and systematic reviews: finding papers indexed in
MEDLINE, EMBASE and CINAHL", Quality and Safety in Health Care, vol. 19, no.
5, pp. 452-461.
Jacobs, S.K. and Levy, J.R., 2006. Mapping the literature of nursing: 1996–2000. Journal
of the Medical Library Association, 94(2), p.206.
Rcpsych.ac.uk. 2020. Retrieved
from:<https://www.rcpsych.ac.uk/docs/default-source/improving-care/nccmh/
suicide-prevention/wave-1-resources/young-people-who-self-harm-a-guide-for-
school-staff.pdf?sfvrsn=e6ebf7ca_2> [Accessed 30 October 2020].
Oermann, M.H. and Hays, J.C., 2015. Writing for publication in nursing. Springer
Publishing Company.
NT4 - Mental Health Nursing Page | 23

Mackenzie, N. and Knipe, S., 2006. Research dilemmas: Paradigms, methods and
methodology. Issues in educational research, 16(2), pp.193-205.
NT4 - Mental Health Nursing Page | 24