Highlight
– A comprehensive 2025 systematic review of 65 studies (14,534 youths) found only moderate-strength evidence that dialectical behavior therapy (DBT) reduces suicidal ideation in adolescents; other psychosocial treatments provide low or insufficient evidence for suicidal outcomes.
– Acute brief interventions, school- and community-based programs, and pharmacologic, neurotherapeutic, and emerging therapies remain inadequately studied in youths at heightened suicide risk.
– The evidence base lacks consistent adverse-event reporting, diverse and representative samples, and trials testing medication or device-based therapies—creating clear research and implementation gaps.
Background: the clinical and public-health context
Suicide is a leading cause of death among young people worldwide and constitutes a growing public-health emergency in many countries. Adolescents and young adults face rising rates of suicidal ideation, attempts, and deaths, with notable variation by sex, racial/ethnic group, and exposure to violence or trauma. Clinicians, health systems, schools, and communities are under pressure to identify and deploy effective interventions tailored to developmental stage and social context. Robust evidence about which treatments reduce suicidal thoughts and behaviors in youths is therefore critical to guide clinical practice and policy.
Study design and scope
A systematic review published in JAMA Pediatrics (Sim et al., 2025) synthesized randomized clinical trials, comparative observational studies, and before-after studies assessing psychosocial, pharmacologic, neurotherapeutic, emerging, and combination interventions for youths with heightened suicide risk. The search spanned January 1, 2000, to September 26, 2024, across multiple databases and gray literature. Eligible populations were aged 5–24 years and included adolescents from racial/ethnic minority groups at increased risk or individuals exposed to violence. Two independent reviewers selected and appraised studies. In total the review included 65 studies—33 randomized clinical trials (RCTs), 13 comparative observational studies, and 19 before-after studies—enrolling 14,534 patients (median age 15.1 years; 75.1% female).
Interventions assessed
Psychosocial strategies formed the bulk of evidence and were categorized as:
- Psychotherapeutic programs (33 studies): cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), collaborative assessment and management of suicidality (CAMS), dynamic deconstructive psychotherapy, attachment-based family therapy, and family-focused therapy.
- Acute/brief psychosocial interventions (19 studies): safety planning, family-based crisis management, motivational interviewing during crisis encounters, continuity-of-care after crisis, and brief adjunctive treatments.
- School- and community-based programs (13 studies): social-network interventions, school-based skills curricula, gatekeeper and awareness programs, and culturally tailored community adjuncts.
Pharmacologic agents, neurotherapeutics (e.g., ECT, TMS), and many emerging therapies were largely unstudied in the youth populations at heightened risk of suicide.
Key findings
This systematic review’s principal conclusions are summarized below. All outcomes and strength-of-evidence statements derive from the review (Sim et al., 2025).
Overall evidence landscape
Most trials evaluated psychosocial interventions; however, heterogeneity in patient selection, comparator conditions, outcome measurement, and follow-up duration limited pooled inferences. Notably, the majority of included participants were female adolescents, reducing generalizability to males and to younger children. Adverse events were not systematically reported across trials.
Dialectical behavior therapy (DBT)
DBT showed a moderate strength of evidence for reducing suicidal ideation in adolescents. Multiple RCTs and comparative studies support DBT’s beneficial effect on ideation and, in some trials, on self-harm frequency. Effect sizes varied across studies but were clinically meaningful in primary reports cited by the review. DBT protocols tailored for adolescents commonly integrate family components and skills training focused on emotion regulation, distress tolerance, and interpersonal effectiveness—content that plausibly targets mechanisms underpinning suicidal crises in this age group.
Other psychotherapies (CBT, family therapies, CAMS, others)
Evidence for CBT, family therapies, CAMS, and other psychotherapeutic modalities was generally graded as low or insufficient for reducing suicidal outcomes. Some trials showed benefits on secondary outcomes (depression symptoms, treatment engagement), but evidence was inconsistent for preventing suicidal ideation, attempts, or repeated self-harm events. Heterogeneity in intervention content and comparator care, and relatively small sample sizes in many trials, limited confident conclusions.
Brief and acute interventions
Brief crisis-oriented strategies—safety planning, single-session interventions, and post-discharge continuity programs—are frequently implemented in emergency and acute-care settings, but the review found low or insufficient evidence for sustained reductions in suicidal behavior. Some trials reported improved linkage to outpatient care or short-term reductions in ideation, but longer-term outcomes and effect on suicide attempts were inadequately powered or inconsistent.
School and community programs
School-based curricula, gatekeeper training, and community-tailored programs showed mixed results. Some programs increased knowledge and identification of at-risk youth but yielded limited or inconsistent effects on behavioral outcomes such as attempts. Cultural adaptation and community engagement were emphasized in several studies, but rigorous evidence for reductions in suicidal behaviors in at-risk youths remained scarce.
Pharmacologic, neurotherapeutic, and emerging therapies
The evidence base for medication and device-based interventions in youths at heightened risk of suicide was largely nonexistent or insufficient. Trials specifically enrolling youth with elevated suicide risk and testing antidepressants, antipsychotics, mood stabilizers, ketamine/esketamine, transcranial magnetic stimulation (TMS), or electroconvulsive therapy (ECT) were absent or too limited to inform practice. This represents a major evidence gap, given the common use of medications for co-occurring psychiatric disorders.
Harms and adverse-event reporting
Alarmingly, none of the reviewed studies provided systematic reporting of adverse events related to interventions as they pertain to suicidal outcomes. This omission hampers risk–benefit assessment and clinical decision-making, especially for higher-risk or pharmacologic interventions where serious harms may occur.
Expert commentary and interpretation
The Sim et al. review provides a sobering assessment: despite a broad literature on adolescent mental health interventions, robust evidence specifically demonstrating reduction in suicidal thoughts and behaviors in high-risk youths is limited. DBT emerges as the most consistently supported psychotherapy, aligning with prior smaller trials and clinical experience showing benefit for adolescents with self-harm. However, even for DBT, translational challenges remain—training intensity, fidelity, and service-system capacity constrain scalable implementation.
From a mechanistic standpoint, DBT’s focus on emotion regulation, distress tolerance, and interpersonal functioning targets proximal drivers of suicidal crises. By contrast, many brief or school-based programs primarily aim to increase awareness and referral—important upstream goals that may not directly reduce suicidal behavior without adequate access to effective downstream treatments. Lack of pharmacologic and device-trial data in high-risk youth is particularly striking and leaves clinicians to extrapolate from adult literature or treat comorbidities without trial-based guidance.
Limitations of the evidence base include overrepresentation of female adolescents, limited racial and socioeconomic diversity, short follow-up durations, and inconsistent outcome definitions. The review also highlights a pervasive failure to report harms—an ethical and methodological shortcoming.
Clinical and policy implications
- Where feasible, DBT-informed programs should be considered for adolescents presenting with recurrent suicidal ideation or self-harm, with attention to training, fidelity, and inclusion of caregivers.
- Safety planning and brief crisis interventions remain pragmatic front-line tools for acute settings but should be coupled with structured follow-up and linkage to evidence-based psychotherapies.
- Clinicians must recognize the limited data for pharmacologic interventions targeted to suicide risk itself; medication decisions should focus on treating comorbid disorders with careful monitoring and shared decision-making.
- Health systems and policymakers should prioritize funding for rigorous trials, workforce training, and implementation research to scale effective psychosocial treatments and evaluate pharmacologic and neuromodulatory options in youth populations.
Research priorities
Key research needs identified by the review include:
- Large, adequately powered RCTs with standardized suicide outcomes (ideation, attempts, self-harm) and longer-term follow-up.
- Trials that enroll more diverse and representative samples by sex, race/ethnicity, socioeconomic status, and age (including young children and young adults up to 24).
- Rigorous evaluation of pharmacologic (including rapid-acting agents) and neurotherapeutic interventions in high-risk youth, with mandatory adverse-event reporting.
- Implementation studies examining fidelity, cost-effectiveness, and models for scaling DBT and other evidence-based psychotherapies in low-resource settings and schools.
- Development and testing of multilevel, trauma-informed interventions that integrate family, school, and community resources.
Conclusion
The 2025 systematic review by Sim et al. documents a limited and uneven evidence base for interventions to prevent suicidal thoughts and behaviors among youths at heightened risk. DBT has the strongest support for reducing suicidal ideation, but other psychosocial approaches provide low or insufficient evidence, and medication- or device-based strategies remain largely unstudied. Clinicians should prioritize evidence-based psychosocial care where available, ensure safety planning and close follow-up after crises, and exercise caution when extrapolating adult data to younger patients. Substantial investment in rigorous, inclusive, and safety-focused research is urgently needed to close gaps and guide practice.
Funding and clinicaltrials.gov
Funding and trial registration details for the systematic review are reported by Sim et al. (JAMA Pediatr. 2025); readers should consult the original publication for specific grant and conflict-of-interest statements. Ongoing and future randomized trials in youth suicide prevention should be registered in ClinicalTrials.gov; clinicians and researchers are advised to check ClinicalTrials.gov for current trial listings relevant to pediatric suicide interventions.
References
1. Sim L, Murad MH, Croarkin PE, et al. Suicide Interventions for Youths: A Systematic Review. JAMA Pediatr. 2025;179(11):1217-1224. doi:10.1001/jamapediatrics.2025.3485. PMID: 41021221.
2. World Health Organization. Suicide. https://www.who.int/news-room/fact-sheets/detail/suicide. Accessed December 2024.
3. Centers for Disease Control and Prevention. Suicide Prevention. https://www.cdc.gov/suicide/index.html. Accessed December 2024.
Note: This article summarizes and interprets the evidence reported in the referenced systematic review and related public-health resources. It is intended for clinicians and policy-makers; it is not a substitute for individualized clinical judgment.
