WITHDRAWN: Psychosocial and pharmacological treatments for deliberate self harm

This review has been withdrawn because the topic has been split into three separate reviews, one on psychosocial interventions for self‐harm in adults; another on interventions for self‐harm in children and adolescents; and a third on pharmacological interventions for self‐harm in adults.

The editorial group responsible for this previously published document have withdrawn it from publication.

Pharmacological interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm.

OBJECTIVES

To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013.

SELECTION CRITERIA

We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.

What is important in being cured from: does discordance between physicians and patients matter? (2)

AIMS

The influence of discordance in what is important in being cured from depression on clinical outcome at 6 months, assessed with a divergence index.

METHODS

304 outpatients treated for depression by general practitioners or by psychiatrists and completing a 6-month treatment period: a divergence index (divergence between physician and patient view on what is important in being cured from depression) was calculated for each physician-patient pair. The relation between this index and outcome at 6 months was analyzed (including depressive, anxious and somatic symptom severity, positive effect, functional impairment and quality of life (psychological and social relations).

RESULTS

Response rates (50% improvement) were 65.9% for depressive symptomatology and 46.2% for anxious symptomatology. The subgroup with a poor physician-patient agreement (highest quartile) on expectations had a worse clinical outcome than the subgroup with an excellent physician-patient agreement (lowest quartile): differences in response rate between these groups ranged from 9% to 27%; this difference reached statistical significance for 3 outcome variables (anxiety, positive effect and social relationships).

CONCLUSIONS

The study shows that outcomes with standard antidepressant drugs are still suboptimal and that discordance between what patients׳ and physicians׳ consider important in the definition of cure from depression significantly influences clinical outcomes at 6 months.

What is important in being cured from depression? Discordance between physicians and patients (1)

AIMS

The comparison of what physicians and patients consider important in being cured from depression.

METHODS

426 outpatients (in primary care and in psychiatric care) with a clinical diagnosis of major depression were included: at the start of antidepressant treatment, the importance of a range of items for being cured from depression (depressive, anxious and somatic symptoms, positive affect, functional impairment, quality of life) was assessed in physicians and patients separately and a ranking was made; after 3 months of treatment, the importance of these items for being cured from depression was re-assessed in the patients.

RESULTS

The items ranked top 10 by physicians mainly contain depressive symptoms while those ranked top 10 by patients mainly contain positive affect items and this attention to positive affect even increases at 3 months follow-up and is higher in patients with recurrent depression than in patients with a first episode of depression. Somatic symptoms consistently get the lowest ranking, as well in physicians as in patients.

CONCLUSIONS

Physicians differ significantly from patients in what they consider important for 'being cured from depression': physicians mainly focus on alleviation of depressive symptoms while patients mainly focus on the restoration of positive affect.

Self-directedness: an indicator for clinical response to the HF-rTMS treatment in refractory melancholic depression

Although well-defined predictors of response are still unclear, clinicians refer a variety of depressed patients for a repetitive Transcranial Magnetic Stimulation (rTMS) treatment. It has been suggested that personality features such as Harm Avoidance (HA) and self-directedness (SD) might provide some guidance for a classical antidepressant treatment outcome. However, to date no such research has been performed in rTMS treatment paradigms. In this open study, we wanted to examine whether these temperament and character scores in particular would predict clinical outcome in refractory unipolar depressed patients when a typical high-frequency (HF)-rTMS treatment protocol is applied. Thirty six unipolar right-handed antidepressant-free treatment resistant depressed (TRD) patients, all of the melancholic subtype, received 10 HF-rTMS sessions applied to the left dorsolateral prefrontal cortex (DLPFC). All patients were classified as at least stage III TRD and were assessed with the Temperament and Character Inventory (TCI) before a HF-rTMS treatment. Only the individual scores on SD predicted clinical outcome. No other personality scales were found to be a predictor of this kind of application. Our results suggest that refractory MDD patients who score higher on the character scale SD may be more responsive to the HF-rTMS treatment.

The role of neuroimaging in our understanding of the suicidal brain

This paper provides a review of the literature on neuroimaging studies of suicidal behaviour, and discusses the relevance of these studies for our understanding of suicidal behaviour. Main findings from molecular imaging studies include a reduced prefrontal perfusion or metabolism and a blunted increase in activation when challenged in association with a history of suicide attempts. Moreover, impairment of the prefrontal serotonergic system in association with suicidal behaviour is demonstrated in a number of studies. Recent structural and functional imaging studies show changes in cortical and subcortical areas and their connections. A number of methodological issues hamper the interpretation of findings. Nevertheless, when findings from studies using divergent techniques are taken together there is increasing evidence of the involvement of a fronto-cingulo-striatal network in suicidal behaviour. This involvement is supported additionally by findings from neuropsychological studies, which demonstrate changes in decision-making processes in association with suicidal behaviour that rely on the same network. Further study is needed to translate the increasing knowledge from neuroimaging studies in clinical tools for the prediction and prevention of suicidal behaviour.

Attempted Suicide in Patients With Eating Disorders

Background: Suicide is a major cause of mortality for patients with eating disorders (ED), especially for patients with anorexia nervosa. Attempted suicide is also relatively common in patients with anorexia or bulimia nervosa. Aims: This study aimed at examining associations between attempted suicide and trait- and state-dependent characteristics in a large clinical population of ED patients. Method: The sample consisted of 1,436 in- and outpatients of the Centre for Eating Disorders of the Ghent University Hospital. Measures of ED symptoms, psychopathology, and personality traits were compared between ED patients with and ED patients without a history of attempted suicide. Results: A history of attempted suicide was found in 11.8% of the ED patients and lifetime suicidal ideation was reported by 43.3%. Multivariate analyses showed that a history of attempted suicide was associated with higher scores on depression, purging symptomatology, early-developed cognitive schemes (impaired autonomy and increased inhibition), and social insecurity. Conclusion: These findings support the increased risk of suicidal behavior in ED. The presence of particular personality traits, of cognitive schemes, and of purging and depressive symptoms should increase vigilance for suicidal behavior.

The acute effects of accelerated repetitive Transcranial Magnetic Stimulation on suicide risk in unipolar depression: preliminary results

BACKGROUND

Suicide is a major health concern. Effective acute interventions are lacking. Recent studies have suggested an acute decrease of suicidal ideations following repetitive Transcranial Magnetic Stimulation (rTMS). However, placebo effects could not be excluded. We aimed to evaluate the acute effect of accelerated intermittent theta burst stimulation (TBS) on suicide risk in depression.

SUBJECTS AND METHODS

In 12 suicidal therapy-resistant depressed patients accelerated intermittent TBS was delivered on the left dorsolateral prefrontal cortex in a randomized, sham-controlled cross-over fashion. Patients received 20 sessions spread over 4 days. The change in severity of suicidal ideation was measured by the Beck Scale of Suicidal Ideation (SSI) before and after treatment.

RESULTS

We found a significant decrease of SSI score over time; unrelated to active or sham stimulation. Furthermore, the attenuation of suicidal thinking was not merely related to depression severity changes caused by TBS.

CONCLUSIONS

Accelerated TBS treatment in depressed suicidal patients was found to be safe and well tolerated and may have the potential to acutely decrease suicidal ideations. However, the efficacy compared to sham has not yet been proven and further sham-controlled research including longer follow-up is needed to substantiate these preliminary findings.

Is there a neuroanatomical basis of the vulnerability to suicidal behavior? A coordinate-based meta-analysis of structural and functional MRI studies

Objective: We conducted meta-analyses of functional and structural neuroimaging studies comparing adolescent and adult individuals with a history of suicidal behavior and a psychiatric disorder to psychiatric controls in order to objectify changes in brain structure and function in association with a vulnerability to suicidal behavior.

Methods: Magnetic resonance imaging studies published up to July 2013 investigating structural or functional brain correlates of suicidal behavior were identified through computerized and manual literature searches. Activation foci from 12 studies encompassing 475 individuals, i.e., 213 suicide attempters and 262 psychiatric controls were subjected to meta-analytical study using anatomic or activation likelihood estimation (ALE).

Result: Activation likelihood estimation revealed structural deficits and functional changes in association with a history of suicidal behavior. Structural findings included reduced volumes of the rectal gyrus, superior temporal gyrus and caudate nucleus. Functional differences between study groups included an increased reactivity of the anterior and posterior cingulate cortices.

Discussion: A history of suicidal behavior appears to be associated with (probably interrelated) structural deficits and functional overactivation in brain areas, which contribute to a decision-making network. The findings suggest that a vulnerability to suicidal behavior can be defined in terms of a reduced motivational control over the intentional behavioral reaction to salient negative stimuli.

The neurobiology of suicide

The stress-diathesis model posits that suicide is the result of an interaction between state-dependent (environmental) stressors and a trait-like diathesis or susceptibility to suicidal behaviour, independent of psychiatric disorders. Findings from post-mortem studies of the brain and from genomic and in-vivo neuroimaging studies indicate a biological basis for this diathesis, indicating the importance of neurobiological screening and interventions, in addition to cognitive and mood interventions, in the prevention of suicide. Early-life adversity and epigenetic mechanisms might explain some of the link between suicide risk and brain circuitry and neurochemistry abnormalities. Results from a range of studies using diverse designs and post-mortem and in-vivo techniques show impairments of the serotonin neurotransmitter system and the hypothalamic-pituitary-adrenal axis stress-response system in the diathesis for suicidal behaviour. These impairments manifest as impaired cognitive control of mood, pessimism, reactive aggressive traits, impaired problem solving, over-reactivity to negative social signs, excessive emotional pain, and suicidal ideation, leading to suicidal behaviour. Biomarkers related to the diathesis might help to inform risk-assessment procedures and treatment choice in the prevention of suicide.

A CBT-Based Psychoeducational Intervention for Suicide Survivors

Background: Bereavement following suicide is associated with an increased vulnerability for depression, complicated grief, suicidal ideation, and suicide. There is, however, a paucity of studies of the effects of interventions in suicide survivors. Aims: This study therefore examined the effects of a cognitive behavioral therapy (CBT)-based psychoeducational intervention on depression, complicated grief, and suicide risk factors in suicide survivors. Method: In total, 83 suicide survivors were randomized to the intervention or the control condition in a cluster randomized controlled trial. Primary outcome measures included maladaptive grief reactions, depression, suicidal ideation, and hopelessness. Secondary outcome measures included grief-related cognitions and coping styles. Results: There was no significant effect of the intervention on the outcome measures. However, the intensity of symptoms of grief, depressive symptoms, and passive coping styles decreased significantly in the intervention group but not in the control group. Conclusion: The CBT-based psychoeducational intervention has no significant effect on the development of complicated grief reactions, depression, and suicide risk factors among suicide survivors. The intervention may, however, serve as supportive counseling for suicide survivors.

Immigration and recommended care after a suicide attempt in Europe: equity or bias?

This report describes the investigation of care recommendations in the medical system across European countries to immigrants who attempted suicide. Data from seven European countries with 8865 local and 2921 immigrant person-cases were derived from the WHO/EURO Multicentre Study on Suicidal Behaviour and ensuing MONSUE (Monitoring Suicidal Behaviour in Europe) project. The relationship between immigrant status and type of aftercare recommended was analysed with binary logistic regression, adjusting for gender, age, method of attempt and the Centre collecting the data. Clear disparities were identified in the care recommendation practices toward immigrants, compared with hosts, over and above differing policies by the European Centres.

Do general practitioners and psychiatrists agree about defining cure from depression? The DEsCRIBE™ survey

BACKGROUND

This study aimed to document the outcome dimensions that physicians see as important in defining cure from depression. The study also aimed to analyse physicians' attitudes about depression and to find out whether they affect their prescribing practices and/or the outcome dimensions that they view as important in defining cure.

METHODS

A 51-item questionnaire based on six validated scales was used to rate the importance of several depression outcome dimensions. Physicians' attitudes about depression were also assessed using the Depression Attitude Scale. Overall, 369 Belgian physicians (264 general practitioners [GPs]; 105 psychiatrists) participated in the DEsCRIBE™ survey.

RESULTS

GPs and psychiatrists strongly agreed that functioning and depressive symptomatology were most important in defining cure; anxious and somatic symptomatology was least important. GPs and psychiatrists differed in their attitudes about depression (p <0.001). Logistic regression revealed that the attitudes of GPs - but not psychiatrists - were significantly associated with their rates of antidepressant prescription (p < 0.001) and that certain attitudes predicted which outcome dimensions were seen as important in defining cure.

CONCLUSIONS

Belgian GPs and psychiatrists strongly agreed on which criteria were important in defining cure from depression but differed in their attitudes about depression. The outcome dimensions that were considered important in defining cure were influenced by physicians' attitudes - this was more pronounced in GPs than in psychiatrists.

The functional neuroanatomy of mental pain in depression

This study aimed at determining the functional neuroanatomy of mental pain, a hitherto neglected symptom in the study of depression, which according to DSM-IV is stronglylinked with suicide. Mental pain (measured with the Orbach & Mikulincer Mental Pain Scale), suicidal ideation (measured using the Hamilton Rating Scale for Depression), hopelessness (measured using Beck's Hopelessness Scale), and regional cerebral blood flow as measured with single photon emission computed tomography were assessed in 39 depressed individuals. Levels of mental pain were significantly and positively associated with suicidal ideation and levels of hopelessness. When compared with patients with low levels of mental pain, those with high levels of mental pain showed relatively increased perfusion in the right dorsolateral prefrontal cortex, occipital cortex and inferior frontal gyrus and in the left inferior temporal gyrus, and relatively decreased perfusion at the medulla. The findings indicate that mental pain in depressed patients is associated with an increased risk of suicide and that high levels of mental pain are associated with changes in perfusion in brain areas that are involved in the regulation of emotions. Further study is warranted to understand whether this association reflects increased emotional processing or decreased cognitive control over mental pain in depressed individuals.

A comparative follow-up study of aftercare and compliance of suicide attempters following standardized psychosocial assessment

This comparative longitudinal study investigated aftercare and compliance of attempted suicide patients after standardized psychosocial assessment. Structured interviews were conducted 1 month (FU1) and 6 months (FU2) after an index suicide attempt. Assessment was associated with more frequent discussion of treatment options with the patient at the hospital and a shorter interval between discharge and contacting the general practitioner (GP). A near significant effect was found for discussing the suicide attempt with the GP more frequently and with start or change of the medication scheme after the index attempt. The current findings support the use of a standardized tool for the assessment of suicide attempters and are in line with the chain of care model for suicide attempters.

Suicide

Suicide receives increasing attention worldwide, with many countries developing national strategies for prevention. Rates of suicide vary greatly between countries, with the greatest burdens in developing countries. Many more men than women die by suicide. Although suicide rates in elderly people have fallen in many countries, those in young people have risen. Rates also vary with ethnic origin, employment status, and occupation. Most people who die by suicide have psychiatric disorders, notably mood, substance-related, anxiety, psychotic, and personality disorders, with comorbidity being common. Previous self-harm is a major risk factor. Suicide is also associated with physical characteristics and disorders and smoking. Family history of suicidal behaviour is important, as are upbringing, exposure to suicidal behaviour by others and in the media, and availability of means. Approaches to suicide prevention include those targeting high-risk groups and population strategies. There are, however, many challenges to large-scale prevention, especially in developing countries.

Sociodemographic and psychopathological risk factors for repetition of attempted suicide: a 5-year follow-up study

The present study examines the association between repetition of suicide attempts and sociodemographic and psychopathological characteristics of patients during a 5-year follow-up period. Participants were 874 suicide attempters referred to the University Hospital of Ghent, among whom 361 (41.3%) patients were available for follow-up analysis. Within 5 years, 29.2% of those admitted for an index suicide attempt repeated non-fatal suicidal behavior. Repetition of suicidal behavior was associated with high scores on measures of psychopathology. In addition, the risk of repetition was increased if the patient was female, aged between 20 and 49, and had a lower education. Multivariate analysis showed significant results for age, the Buglass & Horton Risk of Repetition Scale and for anxiety. Repetition of suicidal behavior is associated with high anxiety, severe depression, more psychiatric symptoms and is increased in young patients.

Deliberate self-harm in adolescents: comparison between those who receive help following self-harm and those who do not

This international comparative study addresses differences between adolescents who engage in deliberate self-harm (DSH) and who receive help following the DSH episode versus those who do not. A standardised self-report questionnaire was completed by pupils aged 14-17 in Australia, Belgium, England, Hungary, Ireland, The Netherlands, and Norway (n=30,532). An act of DSH in the year prior to the study was reported by 1660 participants. Nearly half (48.4%) had not received any help following DSH, 32.8% had received help from their social network only and 18.8% from health services. Except for Hungary, cross-national comparisons revealed remarkably similar findings. Adolescents who had been in contact with health services following DSH reported more often a wish to die, lethal methods, alcohol/drug problems and DSH in the family compared to those who had not. However, those who received no help or help from their social network only were also heavily burdened.

Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study

BACKGROUND

Deliberate self-harm among young people is an important focus of policy and practice internationally. Nonetheless, there is little reliable comparative international information on its extent or characteristics. We have conducted a seven-country comparative community study of deliberate self-harm among young people.

METHOD

Over 30,000 mainly 15- and 16-year-olds completed anonymous questionnaires at school in Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway. Study criteria were developed to identify episodes of self-harm; the prevalence of self-harm acts and thoughts, methods used, repetition, reasons given, premeditation, setting for the act, associations with alcohol and drugs, hospitalisation, and whether other people knew, were examined.

RESULTS

Self-harm was more than twice as common among females as males and, in four of the seven countries, at least one in ten females had harmed herself in the previous year. Additional young people had thought of harming themselves without doing so. More males and females in all countries except Hungary cut themselves than used any other method, most acts took place at home, and alcohol and illegal drugs were not usually involved. The most common reasons given were 'to get relief from a terrible state of mind' followed by 'to die', although there were differences between those cutting themselves and those taking overdoses. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else. Just over half those who had harmed themselves during the previous year reported more than one episode over their lifetime.

CONCLUSIONS

Deliberate self-harm is a widespread yet often hidden problem in adolescents, especially females, which shows both similarities and differences internationally.

Deliberate self-harm in young people: differences in prevalence and risk factors between the Netherlands and Belgium

BACKGROUND

This study aimed to examine prevalence and risk factors of deliberate self-harm in Dutch and Dutch-speaking Belgian adolescents.

METHOD

A cross sectional survey using an anonymous self report questionnaire was performed in both countries. Data on 4,431 Belgian and 4,458 Dutch 15-16 year-old school pupils were analyzed.

RESULTS

Results showed a significant difference between the two countries indicating that lifetime and past year prevalence of deliberate self-harm were both 2.8 times higher in Belgian adolescents than in Dutch adolescents. Further analyses identified differences in the prevalence of factors associated with deliberate self-harm, with Belgian adolescents showing significant higher scores on anxiety, less problem-oriented coping and more common use of alcohol and soft drugs. Belgian adolescents were also at higher risk for the experience of several life events in the previous year and before that such as conflicts with peers, parents and partner, being bullied at school or exposure to suicidal behavior in family and friends. In addition, Belgian adolescents showed less communication with family or teachers about their problems and difficulties.

CONCLUSIONS

The results of the study suggest that the increased risk of deliberate self-harm among Belgian adolescents may be associated with an increased reporting of several important life events and with additional ineffective problem-solving such as less problem-oriented coping, more substance use and less communication about their problems. These results support the assumption that sociocultural aspects of nations can influence the risk of deliberate self-harm and are important to consider when developing prevention strategies.

Cross-national comparisons of the association between alcohol consumption and deliberate self-harm in adolescents

How differences in drinking patterns may affect the impact of alcohol consumption on deliberate self-harm among adolescents is explored in this international comparative study. Schools in Australia, Belgium, England, Hungary, Ireland, the Netherlands, and Norway (N = 30,532) were surveyed. In all countries the risk of deliberate self-harm was significantly elevated among adolescents who reported some or numerous episodes of intoxication, controlling for confounding factors. The results support the assumption that intoxication is significantly related to the association between alcohol consumption and deliberate self-harm in adolescents.

Deliberate self-harm in adolescents

PURPOSE OF REVIEW

To review literature on young people who deliberately harmed themselves that was published between March 2005 and December 2006 in English language journals.

RECENT FINDINGS

Recent follow-up studies have confirmed that deliberate self-harm at a young age is an important indication of mental health problems in later life, including a strongly increased risk of subsequent suicidal behavior. Main recent research includes study of risk factors and predictors of deliberate self-harm, and continuing study of the effects of pharmacological treatment, in particular selective serotonin reuptake inhibitors, in children and adolescents.

SUMMARY

Recent findings regarding risk factors of adolescent deliberate self-harm confirm the importance of depressive disorders, deficient problem solving, exposure to suicidal behavior and familial characteristics. More biological studies of young people are required to provide evidence regarding neurobiological correlates of risk factors of suicidality in young people. The association between the use of antidepressants in depressed children and adolescents and the emergence of suicidal behavior continues to be a matter of debate due to the conflicting evidence from ecological or observational studies and meta-analyses. Although psychotherapeutic approaches have been examined less extensively, the results regarding cognitive behavior therapy in depressed and suicidal young people are clearly positive. Measures to prevent suicidal behavior in young people require further research.