• The current body of evidence is derived primarily from racially and ethnically diverse females aged between 12 and 18 years, who had depression, bipolar disorder, or suicidal ideations.
• Low strength of evidence supports that dialectical behavior therapy (DBT) may reduce suicidal ideation (SI) and nonsuicidal self-injury (NSSI) when administered as a multicomponent treatment over 6 months. However, the effectiveness was not durable and did not differ from individual and group supportive therapy at 6 to 12 months followup. Evidence supporting an effect on other outcomes such as suicidal attempts (SA), emergency department (ED) visits and hospital admission is insufficient. Evidence supporting shorter or modified versions of DBT is insufficient.
• Low strength of evidence supports that cognitive behavioral therapy (CBT) may be associated with a trivial or no effect on SI, SA, or self-injury.
• The current evidence is insufficient to support an effect of several psychosocial therapies on SI and SA in children, adolescents, and young adults, including Collaborative Assessment and Management of Suicidality (CAMS), Attachment-Based Family Therapy (ABFT), and Family-Focused Therapy (FFT).
• The current evidence is insufficient to support an effect of acute interventions delivered in the ED or following discharge on SI and SA in children, adolescents, and young adults. This includes safety planning, family-based crisis interventions, motivational interviewing crisis interventions, continuity of care following crisis, and brief adjunctive treatments.
• The current evidence is insufficient to support an effect of school/community-based psychosocial interventions on SI and SA in children, adolescents, and young adults, including social network interventions, school-based skills interventions, suicide awareness/gatekeeper programs, and community-based, culturally tailored adjunct programs.
• The evidence base on pharmacological treatment for suicidal youths is largely nonexistent at the present time. No eligible study evaluated neurotherapeutics therapies.
• The uncertainty about the effectiveness of most interventions compared with group or supportive care suggests that nonspecific therapeutic factors common to all psychotherapeutic approaches and supportive treatments, such as empathy, therapeutic alliance, and contact with the healthcare system, might contribute to outcomes more than the therapeutic strategies themselves.

Background: Suicide is a leading cause of death in young people and an escalating public health crisis. We aimed to assess the effectiveness and harms of available treatments for suicidal thoughts and behaviors in youths at heightened risk for suicide.

Methods: We conducted a systematic review and searched several databases including MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus® and various grey literature sources from January 1, 2000, to November 22, 2023. We included randomized clinical trials (RCTs), comparative observational studies, and before-after studies of psychosocial interventions, pharmacological interventions, neurotherapeutics, emerging therapies, and combinations therapies. Eligible patients were youths (aged 5 to 24 years) who had a heightened risk for suicide, including suicidal ideation, prior attempts, hospital discharge for mental health treatment, or command hallucinations; were identified as high risk on validated questionnaires; were adolescents from racial/ethnic minority groups known to be at increased risk of suicide; were from the lesbian, gay, bisexual, transgender, questioning, or queer (LGBTQ+) community; or were exposed to high levels of crime/violence. Pairs of independent reviewers selected and appraised studies.

Results: We included 61 studies reporting on 14,086 patients (31 RCTs, 12 comparative observational studies, and 18 before-after studies). Psychosocial interventions identified from the studies comprised psychotherapy interventions (Cognitive Behavior Therapy, Dialectical Behavior Therapy, Collaborative Assessment and Management of Suicidality, Attachment-Based Family Therapy, and Family-Focused Therapy), acute (i.e., 1 to 4 sessions/contacts) psychosocial interventions (safety planning, family-based crisis management, motivational interviewing crisis interventions, continuity of care following crisis, and brief adjunctive treatments), and school/community-based psychosocial interventions (social network interventions, school-based skills interventions, suicide awareness/gatekeeper programs, and community-based, culturally tailored adjunct programs). For most categories of psychotherapies, acute interventions, or school/community-based interventions, there was insufficient strength of evidence and uncertainty about reducing suicidal thoughts or attempts. None of the studies evaluated adverse events associated with the interventions. The evidence base on pharmacological treatment for suicidal youths was largely nonexistent at the present time. No eligible study evaluated neurotherapeutics or emerging therapies.

Conclusion: The current evidence on available interventions targeting youths at heightened risk of suicide is uncertain. Medication, neurotherapeutics, and emerging therapies remain unstudied in this population. Given that most treatments were adapted from adult protocols, this limited evidence base calls for the development of novel, developmentally- and trauma-informed treatments, as well as multi-level interventions to target the rising suicide risk in youths.