Psychosocial interventions following self-harm: systematic review of their efficacy in preventing suicide

Cross-national prevalence and risk factors for suicidal ideation, plans and attempts

BACKGROUND

Suicide is a leading cause of death worldwide; however, the prevalence and risk factors for the immediate precursors to suicide - suicidal ideation, plans and attempts - are not wellknown, especially in low- and middle-income countries.

AIMS

To report on the prevalence and risk factors for suicidal behaviours across 17 countries.

METHOD

A total of 84 850 adults were interviewed regarding suicidal behaviours and socio-demographic and psychiatric risk factors.

RESULTS

The cross-national lifetime prevalence of suicidal ideation, plans, and attempts is 9.2% (s.e.=0.1), 3.1% (s.e.=0.1), and 2.7% (s.e.=0.1). Across all countries, 60% of transitions from ideation to plan and attempt occur within the first year after ideation onset. Consistent cross-national risk factors included being female, younger, less educated, unmarried and having a mental disorder. Interestingly, the strongest diagnostic risk factors were mood disorders in high-income countries but impulse control disorders in low- and middle-income countries.

CONCLUSION

There is cross-national variability in the prevalence of suicidal behaviours, but strong consistency in the characteristics and risk factors for these behaviours. These findings have significant implications for the prediction and prevention of suicidal behaviours.

Cognitive-Behavioral Interventions to Reduce Suicide Behavior

Suicide behavior is a serious clinical problem worldwide, and understanding ways of reducing it is a priority. A systematic review and meta-analysis were carried out to investigate whether Cognitive-behavioral therapies (CBTs) would reduce suicide behavior. From 123 potential articles, 28 studies met the entry criteria. Overall, there was a highly significant effect for CBT in reducing suicide behavior. Subgroup analysis indicates a significant treatment effect for adult samples (but not adolescent), for individual treatments (but not group), and for CBT when compared to minimal treatment or treatment as usual (but not when compared to another active treatment). There was evidence for treatment effects, albeit reduced, over the medium term. Although these results appear optimistic in advocating the use of CBT in ameliorating suicidal thoughts, plans, and behaviors, evidence of a publication bias tempers such optimism.

Policy on the prevention of suicidal behaviour; one treatment for all may be an unrealistic expectation

In the absence of clear guidelines on suicide prevention there is a pressing need to translate existing and future evidence into policy. Suicide is a behaviour, not a diagnosis, and has diverse underlying pathologies. Interventions have differential effects in specific risk groups, which may include paradoxical increases in risk. For these reasons, policy makers may need to abandon the goal of one treatment for all and focus on the distinct subgroups of patients at risk when selecting, evaluating and implementing preventive interventions. This has implications for the design of future research, but has the potential to increase the utility and cost-effectiveness of the data available, thereby benefiting policy makers, clinicians and patients.

Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning

BACKGROUND

Repetition of self-poisoning is common.

AIMS

To report the 24-month outcomes of a non-obligatory postcard intervention (plus treatment as usual) compared with treatment as usual.

METHOD

In a randomised-controlled trial (Zelen design) conducted in Newcastle, Australia, eight postcards were sent to participants over a 12-month period. The principal outcomes were the proportion of participants with one or more repeat episodes of self-poisoning and the number of repeat episodes per person.

RESULTS

No significant reduction was observed in the proportion of people repeating self-poisoning in the intervention group (21.2%, 95% CI 17.0-25.3) compared with the control group (22.8%, 95% CI 18.7-27.0; chi(2)=0.32, d.f.=1, P=0.57); the difference between groups was -1.7% (95% CI -7.5 to 4.2). There was a significant reduction in the rate of repetition, with an incidence risk ratio of 0.49 (95% CI 0.33-0.73).

CONCLUSIONS

A postcard intervention maintained the halving of the rate of repetition of hospital-treated self-poisoning events over a 2-year period, although it did not significantly reduce the proportion of individuals who repeated self-poisoning.

Policy on the prevention of suicidal behaviour; one treatment for all may be an unrealistic expectation

In the absence of clear guidelines on suicide prevention there is a pressing need to translate existing and future evidence into policy. Suicide is a behaviour, not a diagnosis, and has diverse underlying pathologies. Interventions have differential effects in specific risk groups, which may include paradoxical increases in risk. For these reasons, policy makers may need to abandon the goal of one treatment for all and focus on the distinct subgroups of patients at risk when selecting, evaluating and implementing preventive interventions. This has implications for the design of future research, but has the potential to increase the utility and cost-effectiveness of the data available, thereby benefiting policy makers, clinicians and patients.

Psychotherapy through the phases of bipolar disorder: Evidence for general efficacy and differential effects

The obstacle facing pharmacotherapy for bipolar disorder is that almost half of the patients do not achieve recovery over the duration of treatment. Although the reason for this disappointing clinical outcome remains unclear, structured psychotherapy has helped to fill these gaps in the treatment of bipolar disorder. Psychoeducation, family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy have all received attention in the research literature. In this review, by assessing the outcomes from randomized control trials across the phases of bipolar disorder, we demonstrate that psychotherapy is an effective adjunctive treatment. We also show that the use of psychotherapy for bipolar disorder has differential results depending on when and under what conditions it is administered.