Therapeutic interventions for adolescent suicidal behavior and self-harm: an umbrella review for developing clinical...

South Korea has the highest suicide rate among member countries of the Organisation for Economic Co-operation and Development, reaching 29.1 per 100,000 people in 2024, alongside a concurrent increase in the prevalence of adolescent non-suicidal self-injury (NSSI), estimated at 21.2%-24%, substantially exceeding the global average. Despite this public health crisis, evidence-based clinical practice guidelines specifically addressing adolescent suicidal behavior and NSSI in the Korean context remain lacking. This umbrella review synthesizes evidence on therapeutic interventions to inform the development of clinical practice guidelines.

A systematic search was conducted across five databases (PubMed, Embase, CINAHL, Cochrane CENTRAL, Scopus) for systematic reviews published between January 2015 and December 2024. Eligibility was assessed using a predefined Population, Intervention, Comparison, Outcome framework targeting adolescents and young adults aged 10-24 years. Methodological quality was appraised using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2), and the certainty of evidence was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Both quantitative and narrative systematic reviews were included.

Six systematic reviews (published between 2018 and 2022) encompassing 178 unique primary studies met the eligibility criteria. AMSTAR-2 ratings identified one review as high quality, three as moderate quality, and two as critically low quality. High-certainty evidence supported combination therapy (fluoxetine plus cognitive behavioral therapy (CBT)) over fluoxetine monotherapy, demonstrating significantly improved treatment response rates (RR = 1.12) and reduced one-year recurrence rates (RR = 0.27). For psychotherapy as a stand-alone intervention, high-certainty evidence demonstrated a small effect on self-harm reduction (d = 0.13), and moderate-certainty evidence supported a reduction in suicidal ideation (d = 0.31). However, evidence for widely adopted models-including dialectical behavior therapy for adolescents, mentalization-based treatment for adolescents, attachment-based family therapy, and multisystemic therapy-was uniformly rated as very low certainty, revealing a substantial evidence-practice gap. A substantial proportion of the included reviews did not distinguish between NSSI and suicidal behavior in outcome reporting, limiting differential conclusions.

This umbrella review identified high-certainty evidence supporting fluoxetine plus CBT combination therapy as a first-line recommendation for adolescents with comorbid depression and suicidal risk. The evidence-practice gap for specific psychotherapy models underscores the need for methodologically rigorous primary research. Culturally adapted guidelines incorporating Korea-specific risk factors-including academic pressure, Confucian family values, and cyberbullying-are urgently needed to address the unique epidemiological and sociocultural context of Korean adolescents. This review was prospectively registered in INPLASY(registration number: INPLASY202630082, doi: https://doi.org/10.37766/inplasy2026.3.0082 ).

Not applicable.