Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm

Efficacy of psychotherapeutic interventions for non-suicidal self-injury in adolescent population: Systematic review and meta-analysis

Non-suicidal self-injury (NSSI) is the deliberate and self-inflicted damage to body tissue in the absence of fatal intent, and has become a serious health problem among adolescents. The aim of this study was to evaluate the efficacy of treatment for NSSI in this population through a systematic revision and meta-analysis (PROSPERO ID: 252355). Studies with therapies that reduced NSSI were included. The search was performed in the Medline, APA PsycINFO and PubPsych databases. The synthesis of measures for the main outcome (NSSI reduction) and for secondary outcomes (global functioning change and depressive symptomatology reduction) was performed using a random effects model. The search identified a total of 1881 studies. The systematic review included five studies and the meta-analysis four studies. The summary effect estimate for the standardized mean difference in NSSI was -0.53 (95% CI: -0.82, -0.25), in global functioning it was 0.62 (95% CI: 0.34, 0.91), and in depressive symptomatology it was -0.59 (95% CI: -0.82, -0.36). The certainty of the evidence using the GRADE method is low. We conclude that therapies specifically aimed at reducing NSSI are effective in reducing both NSSI and depressive symptoms while increasing global functioning.

Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis

BACKGROUND

Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables.

METHODS

We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed.

RESULTS

We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome.

CONCLUSIONS

People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.

The effect of cognitive behavioral therapy on future thinking in patients with major depressive disorder: A randomized controlled trial

BACKGROUND

Pessimistic thinking about the future is one of the cardinal symptoms of major depression. Few studies have assessed changes in pessimistic thinking after undergoing cognitive behavioral therapy (CBT). A randomized clinical trial (RCT) was conducted with patients diagnosed with major depressive disorder (MDD) to determine whether receiving a course of CBT affects pessimistic future thinking using a future thinking task.

METHODS

Thirty-one patients with MDD were randomly assigned to either CBT (n = 16) or a talking control (TC) (n = 15) for a 16-week intervention. The main outcomes were the change in response time (RT) and the ratio of the responses for positive valence, measured by the future thinking task. Secondary outcomes included the GRID-Hamilton Depression Rating Scale, the Beck Depression Inventory-Second Edition (BDI-II), the Dysfunctional Attitude Scale (DAS), and the word fluency test (WFT).

RESULTS

Regarding the main outcomes, the CBT group showed reduced RT for the positive valence (within-group Cohen's d = 0.7, p = 0.012) and negative valence (within-group Cohen's d = 0.6, p = 0.03) in the distant future condition. The ratio of positive valence responses in both groups for all temporal conditions except for the distant past condition increased within group (distant future: CBT: Cohen's d = 0.5, p = 0.04; TC: Cohen's d = 0.8, p = 0.008; near future: CBT: Cohen's d = 1.0, p < 0.001; TC: Cohen's d = 1.1, p = 0.001; near past: CBT: Cohen's d = 0.8, p = 0.005; TC: Cohen's d = 1.0, p = 0.002). As for secondary outcomes, the CBT group showed greater improvement than the TC group regarding the need for social approval as measured by the DAS (p = 0.012).

CONCLUSION

Patients with MDD who received CBT showed a reduced RT for the positive and negative valence in the distant future condition. RT in the future thinking task for depressed patients may be a potential objective measure for the CBT treatment process. Because the present RCT is positioned as a pilot RCT, a confirmatory trial with a larger number of patients is warranted to elucidate the CBT treatment process that influences future thinking.

CLINICAL TRIAL REGISTRATION

https://center6.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000021028, identifier UMIN000018155.

Developing a Mobile App for Young Adults with Nonsuicidal Self-Injury: A Prototype Feedback Study

Nonsuicidal self-injury (NSSI) affects approximately 13% of young adults. Though evidence-based treatments for NSSI exist, most young adults do not receive treatment. Digital interventions can provide access to evidence-based treatments for NSSI at scale. Further, preliminary research suggests the acceptability, feasibility, and potential efficacy of digital interventions for NSSI. To date, however, there are few publicly available digital interventions developed specifically for young adults who engage in NSSI. The aim of this study was to solicit young adults' impressions of early app prototypes to identify ways of improving interactive features and content needs. Building on a prior interview study which explored young adults' self-management of NSSI and their use of technology in self-management, this study involved three waves of iterative app prototype feedback sessions with 10 young adults with past month NSSI. In general, participants responded favorably and provided feedback to augment the app to better meet their needs, including adding new features and functionality as well as increasing opportunities for personalization. We discuss two key design challenges related to the roles of tracking and temporality in digital interventions for NSSI, and then frame design considerations related to these challenges within the lived informatics model.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Psychological therapies and non-suicidal self-injury in LGBTIQ in accident and emergency departments in the UK: a scoping review

BACKGROUND

To identify psychological interventions that improve outcomes for those who overdose, especially amongst Lesbian, Gay, Bisexual, Transgender, Intersex and Questioning populations.

OBJECTIVE

To recognize and assess the results from all studies including randomized control trials (RCTs) that have studied the efficiency of psychiatric and psychological assessment of people who have depression that undergo non-suicidal self-injury (NSSI) by self-poisoning, presenting to UK Accident and Emergency Departments.

METHOD

A scoping review of all studies including RCTs of psychiatric and psychological therapy treatments. Studies were selected according to types of engagement and intervention received. All studies including RCTs available in databases since 1998 in the Wiley version of the Cochrane controlled trials register in 1998 till 2021, Psych INFO, Medline, Google Scholar and from manually searching of journals were included. Studies that included information on repetition of the NSSI behaviour were also included. Altogether this amounts to 3900 randomized study participants with outcome data.

RESULTS

Seven trials reported repetition of NSSI as an outcome measure which were classified into four categories. Problem-solving therapy is indicated as a promising therapy and has shown to significantly reduce repetition in participants who NSSI by overdosing than patients in the control treatment groups consisting of standard after care.

CONCLUSION

The data show that manualized cognitive therapy psychological intervention was more effective than TAU after care. However, these differences are not statistically significant with p = .15; CI 0.61, 1.0 which crosses the line of no effect. And psychodynamic interpersonal therapy is more effective than the standard treatment. Despite being only one study in this subgroup the analysis shows a statistical significance with p = .009, CI 0.08; 0.7.

[Psychotherapy after a suicide attempt-current evidence and evaluation]

Suizidversuche gelten als einer der wichtigsten Risikofaktoren für Suizide. Vor diesem Hintergrund wurden in den letzten Jahren diverse Psychotherapieangebote für Personen nach einem Suizidversuch entwickelt und untersucht. Im Rahmen dieses Artikels wird der aktuelle Stand der Effektivitätsforschung zusammengefasst, es werden Beispiele für erfolgreiche suizidfokussierte Psychotherapieprogramme gegeben und der gegenwärtige Forschungs- und Wissensstand wird kritisch reflektiert. Die Ergebnisse von 2 aktuellen Cochrane-Reviews zur Psychotherapie nach selbstverletzendem Verhalten im Kindes‑, Jugend- und Erwachsenenalter sowie Befunde aus 14 weiteren Metaanalysen zur psychologischen Suizidprävention, die in den vergangenen 5 Jahren publiziert wurden, werden überblicksartig dargestellt.

Die kognitive Verhaltenstherapie (KVT) und die dialektisch-behaviorale Therapie (DBT) haben sich als effektiv erwiesen. Insgesamt sind die gemittelten Effektstärken jedoch von geringer Größe und diverse methodische Probleme verunmöglichen weitreichende Schlussfolgerungen. Grundsätzlich kommt der suizidspezifischen Psychotherapie in der individuumszentrierten Suizidprävention besondere Bedeutung zu; die empirische Fundierung und Dissemination entsprechender Programme sind jedoch noch unzureichend.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

OBJECTIVES

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

DATA COLLECTION AND ANALYSIS

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

MAIN RESULTS

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

AUTHORS' CONCLUSIONS

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Bibliotherapy as a Non-pharmaceutical Intervention to Enhance Mental Health in Response to the COVID-19 Pandemic: A Mixed-Methods Systematic Review and Bioethical Meta-Analysis

Background: A non-pharmaceutical treatment offered as psychological support is bibliotherapy, which can be described as the process of reading, reflecting, and discussing literature to further a cognitive shift. The coronavirus disease 2019 (COVID-19) pandemic demands a response to prevent a peak in the prevalence of mental health problems and to avoid the collapse of mental health services, which are scarce and inaccessible due to the pandemic. Thus, this study aimed to review articles on the effectiveness of bibliotherapy on different mental health problems.

Methods: A systematic review was conducted to examine relevant studies that assess the effectiveness of bibliotherapy in different clinical settings as a treatment capable of enhancing a sense of purpose and its surrounding values. To achieve this, a systematic review, including a bioethical meta-analysis, was performed. A variant of the PICO (Participants, Intervention, Comparison, and Outcome) model was used for the search strategy, and the systematic review was conducted in three databases: PubMed, Bireme, and OVID. Inclusion criteria were relevant studies that included the keywords, excluding documents with irrelevant topics, studies on subjects 15 years or younger, and in languages besides Spanish or English. Starting with 707 studies, after three rounds of different quality criteria, 13 articles were selected for analysis, including a hermeneutic analysis, which was followed by a fourth and final recovery round assessing bibliotherapy articles concerning healthcare workers.

Results: Our findings showed that through bibliotherapy, patients developed several capacities, including the re-signification of their own activities through a new outlook of their moral horizon. There are no research road maps serving as guides to conduct research on the use of bibliotherapy to enhance mental health. Additionally, values such as autonomy and justice were closely linked with positive results in bibliotherapy. This implies that bibliotherapy has the potential to have a positive impact in different settings.

Conclusions: Our contribution is to offer a road map that presents state-of-the-art bibliotherapy research, which will assist institutions and healthcare professionals to plan clinical and specific interventions with positive outcomes.

Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

People with Borderline Personality Disorder (BPD) have limited access to long term psychological therapies. Briefer interventions have been developed but trial evidence to support their use has not been reviewed.

AIMS

To examine whether psychological interventions for adults with BPD of six months duration or less improve symptoms, mood, self-harm, suicidal behaviour, and service use.

METHODS

The protocol was prospectively registered (PROSPERO CRD42017063777). Database searches were conducted up to April 2020. Inclusion, data extraction and risk of bias were assessed in duplicate. We identified 27 randomised controlled trials. We conducted random-effects meta-analyses sub-grouping data into delivery method, additional support, and comparison type.

RESULTS

High levels of bias were found for attrition and reporting. Heterogeneity was high in some pooled data. Borderline symptom reductions were greatest for interventions including additional support (SMD. -1.23, 95% C.I. -2.13, -0.33). Planned generic support may be as effective as specialist interventions for borderline symptoms (SMD = -0.11, 95% C.I. -0.51, 0.29) and social functioning (SMD = -0.16., 95% C.I. -0.65, 0.33). Follow-up was limited and direct comparison with post-intervention results was unreliable.

CONCLUSIONS

Short-term interventions may be effective. Access to additional support has an impact on outcomes. It is unclear if symptomatic change is sustained.

Psychological interventions for antisocial personality disorder

BACKGROUND

Antisocial personality disorder (AsPD) is associated with poor mental health, criminality, substance use and relationship difficulties. This review updates Gibbon 2010 (previous version of the review).

OBJECTIVES

To evaluate the potential benefits and adverse effects of psychological interventions for adults with AsPD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 13 other databases and two trials registers up to 5 September 2019. We also searched reference lists and contacted study authors to identify studies.

SELECTION CRITERIA

Randomised controlled trials of adults, where participants with an AsPD or dissocial personality disorder diagnosis comprised at least 75% of the sample randomly allocated to receive a psychological intervention, treatment-as-usual (TAU), waiting list or no treatment. The primary outcomes were aggression, reconviction, global state/functioning, social functioning and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 19 studies (eight new to this update), comparing a psychological intervention against TAU (also called 'standard Maintenance'(SM) in some studies). Eight of the 18 psychological interventions reported data on our primary outcomes. Four studies focussed exclusively on participants with AsPD, and 15 on subgroups of participants with AsPD. Data were available from only 10 studies involving 605 participants. Eight studies were conducted in the UK and North America, and one each in Iran, Denmark and the Netherlands. Study duration ranged from 4 to 156 weeks (median = 26 weeks). Most participants (75%) were male; the mean age was 35.5 years. Eleven studies (58%) were funded by research councils. Risk of bias was high for 13% of criteria, unclear for 54% and low for 33%. Cognitive behaviour therapy (CBT) + TAU versus TAU One study (52 participants) found no evidence of a difference between CBT + TAU and TAU for physical aggression (odds ratio (OR) 0.92, 95% CI 0.28 to 3.07; low-certainty evidence) for outpatients at 12 months post-intervention. One study (39 participants) found no evidence of a difference between CBT + TAU and TAU for social functioning (mean difference (MD) -1.60 points, 95% CI -5.21 to 2.01; very low-certainty evidence), measured by the Social Functioning Questionnaire (SFQ; range = 0-24), for outpatients at 12 months post-intervention. Impulsive lifestyle counselling (ILC) + TAU versus TAU One study (118 participants) found no evidence of a difference between ILC + TAU and TAU for trait aggression (assessed with Buss-Perry Aggression Questionnaire-Short Form) for outpatients at nine months (MD 0.07, CI -0.35 to 0.49; very low-certainty evidence). One study (142 participants) found no evidence of a difference between ILC + TAU and TAU alone for the adverse event of death (OR 0.40, 95% CI 0.04 to 4.54; very low-certainty evidence) or incarceration (OR 0.70, 95% CI 0.27 to 1.86; very low-certainty evidence) for outpatients between three and nine months follow-up. Contingency management (CM) + SM versus SM One study (83 participants) found evidence that, compared to SM alone, CM + SM may improve social functioning measured by family/social scores on the Addiction Severity Index (ASI; range = 0 (no problems) to 1 (severe problems); MD -0.08, 95% CI -0.14 to -0.02; low-certainty evidence) for outpatients at six months. 'Driving whilst intoxicated' programme (DWI) + incarceration versus incarceration One study (52 participants) found no evidence of a difference between DWI + incarceration and incarceration alone on reconviction rates (hazard ratio 0.56, CI -0.19 to 1.31; very low-certainty evidence) for prisoner participants at 24 months. Schema therapy (ST) versus TAU One study (30 participants in a secure psychiatric hospital, 87% had AsPD diagnosis) found no evidence of a difference between ST and TAU for the number of participants who were reconvicted (OR 2.81, 95% CI 0.11 to 74.56, P = 0.54) at three years. The same study found that ST may be more likely to improve social functioning (assessed by the mean number of days until patients gain unsupervised leave (MD -137.33, 95% CI -271.31 to -3.35) compared to TAU, and no evidence of a difference between the groups for overall adverse events, classified as the number of people experiencing a global negative outcome over a three-year period (OR 0.42, 95% CI 0.08 to 2.19). The certainty of the evidence for all outcomes was very low. Social problem-solving (SPS) + psychoeducation (PE) versus TAU One study (17 participants) found no evidence of a difference between SPS + PE and TAU for participants' level of social functioning (MD -1.60 points, 95% CI -5.43 to 2.23; very low-certainty evidence) assessed with the SFQ at six months post-intervention. Dialectical behaviour therapy versus TAU One study (skewed data, 14 participants) provided very low-certainty, narrative evidence that DBT may reduce the number of self-harm days for outpatients at two months post-intervention compared to TAU. Psychosocial risk management (PSRM; 'Resettle') versus TAU One study (skewed data, 35 participants) found no evidence of a difference between PSRM and TAU for a number of officially recorded offences at one year after release from prison. It also found no evidence of difference between the PSRM and TAU for the adverse event of death during the study period (OR 0.89, 95% CI 0.05 to 14.83, P = 0.94, 72 participants (90% had AsPD), 1 study, very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is very limited evidence available on psychological interventions for adults with AsPD. Few interventions addressed the primary outcomes of this review and, of the eight that did, only three (CM + SM, ST and DBT) showed evidence that the intervention may be more effective than the control condition. No intervention reported compelling evidence of change in antisocial behaviour. Overall, the certainty of the evidence was low or very low, meaning that we have little confidence in the effect estimates reported. The conclusions of this update have not changed from those of the original review, despite the addition of eight new studies. This highlights the ongoing need for further methodologically rigorous studies to yield further data to guide the development and application of psychological interventions for AsPD and may suggest that a new approach is required.

Use of Recorded Poetic Audios to Manage Levels of Anxiety and Sleep Disorders

Anxiety and sleep disorders are highly prevalent affecting millions of people worldwide. Complementary therapies like art therapy, bibliotherapy, and music have been used to manage these problems. The objective of this study was to evaluate levels of anxiety and sleep disorder symptoms of participants before and after a 30-day intervention of listening to short poetic audios. Thirty-one participants listened to audio-taped messages, which associate music and literature for 30 days. Questionnaires were answered by participants prior to the start of the study (baseline collection) and after 30 days (final collection). Setting: the study was done in the city of Ribeirao Preto (Sao Paulo-Brazil). Participants were 31 adults with anxiety symptoms and sleep problems. The scores of the questionnaires were analyzed and compared by the t test for paired samples (α = 0.05), used to evaluate possible differences in anxiety and stress symptoms and sleep disturbances before and after the 30 days of intervention. Significantly lower levels of anxiety and sleep disorders were found after the 30-day intervention. This study reinforces the benefits of music and literature for improving the quality of life of people by reducing levels of anxiety and sleep disorder symptoms.

Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre, randomised controlled trial

Although nonsuicidal self-injury (NSSI) is a clinically significant behavior, evidence-based, specific, time-, and cost-effective treatment approaches are lacking. The aim of this study was to compare the efficacies of a brief cognitive-behavioral psychotherapy manual, the Cutting Down Programme (CDP), and treatment as usual (TAU) in the treatment of adolescent NSSI. We conducted a single-centre randomised controlled trial (RCT). Eligible participants were aged 12-17 years engaging in repetitive NSSI (at least 5 times within the past 6 months). We randomly allocated 74 participants to CDP (n = 37) or TAU (n = 37; in a 1:1 ratio). Outcome measures were administered before treatment (T0), directly after CDP or 4 months after baseline evaluation in the TAU group (T1), and another 6 months later (T2; primary endpoint). Primary outcome was a 50% reduction in NSSI frequency within the past 6 months at 10-month follow-up (T2). Regarding the primary outcome, there were no significant differences between the CDP (n = 26; 70.3%) and TAU group [n = 27; 73.0%; χ²(1) = 0.07; p = 0.797]; NSSI frequency within the past 6 months was significantly reduced at T2 [χ²(1) = 12.45; p < 0.001] with no between-group difference [χ²(1) = 0.14; p = 0.704]. However, we found a significant group x point of measurement interaction [χ²(2) = 7.78; p = 0.021] regarding NSSI within the last month indicating at T1. CDP was equally effective and achieved faster recovery compared to a significantly more intensive TAU in treating adolescent NSSI. The CDP could provide a brief and pragmatic first treatment within a stepped-care model for NSSI in routine clinical care.Clinical Trial Registration The trial was prospectively registered in the German Registry of Clinical Trials (https://www.drks.de; DRKS00003605) and is now complete.

Psychosocial Interventions for People Who Self-Harm: Methodological Issues Involved in Trials to Evaluate Effectiveness

We have assessed the methodological quality of randomized controlled trials (RCTs) of interventions to prevent self-harm repetition and suicide. Trials were identified in two systematic reviews of RCTs of psychosocial treatments following a recent (within six months) episode of self-harm indexed in any of five electronic databases (CCDANCTR-Studies and References, CENTRAL, Medline, Embase, and PsycINFO) between 1 January, 1998 and 29 April, 2015. A total of 66 trials were included, 55 in adults and 11 in children and adolescents. While evidence for efficacy of some approaches has grown, there were few trials from low-to-middle income countries, little information on interventions for males, information on the control condition was often limited, data on suicides were often not reported, and, while trials have increased in size in recent years, most have included too few participants to detect clinically significant results. There are major limitations in many trials of interventions for individuals who self-harm. Improved methodology, especially with regard to study size, provision of details of control therapy, and evaluation of key outcomes, would enhance the evidence base for clinicians and service users.

Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit[Formula: see text]

BACKGROUND. Between 4% to 70% of inpatients engage in self-harming behaviors and effective interventions are needed to address this population. AIM. This article reviews literature from 2007 to 2017 to address treatment and management strategies specific for the treatment of nonsuicidal self-injury in the inpatient psychiatric setting. METHODS. Cochrane, PsycINFO, PubMed, and CINAHL were searched for relevant articles with 34 studies reviewed for applicability to the question, and 9 parsed into a summary of Findings table. RESULTS. Therapeutic approaches that show promise include cognitive behavioral therapy, dialectical behavior therapy, and mentalization as well as medications that act on the serotonergic, dopaminergic, and opioid systems. Effective models of care aim toward enhancing therapeutic relationships with staff, providers, and most important, encouraging the internal shift toward recovery within the patient. CONCLUSIONS. More research with controlled designs in the inpatient setting is needed, however, regardless of which approach is used, the impact of the individual caregiver on the patient's recovery is key.

Problem-solving training: assessing the feasibility and acceptability of delivering and evaluating a problem-solving training model for front-line prison staff and prisoners who self-harm

OBJECTIVES

Problem-solving skills training is adaptable, inexpensive and simple to deliver. However, its application with prisoners who self-harm is unknown. The study assessed the feasibility and acceptability of a problem-solving training (PST) intervention for prison staff and prisoners who self-harm, to inform the design of a large-scale study.

DESIGN AND SETTING

A mixed-methods design used routinely collected data, individual outcome measures, an economic protocol and qualitative interviews at four prisons in Yorkshire and Humber, UK.

PARTICIPANTS

(i) Front-line prison staff, (ii) male and female prisoners with an episode of self-harm in the previous 2 weeks.

INTERVENTION

The intervention comprised a 1 hour staff training session and a 30 min prisoner session using adapted workbooks and case studies.

OUTCOMES

We assessed the study processes-coverage of training; recruitment and retention rates and adequacy of intervention delivery-and available data (completeness of outcome data, integrity of routinely collected data and access to the National Health Service (NHS) resource information). Prisoner outcomes assessed incidence of self-harm, quality of life and depression at baseline and at follow-up. Qualitative findings are presented elsewhere.

RESULTS

Recruitment was higher than anticipated for staff n=280, but lower for prisoners, n=48. Retention was good with 43/48 (89%) prisoners completing the intervention, at follow-up we collected individual outcome data for 34/48 (71%) of prisoners. Access to routinely collected data was inconsistent. Prisoners were frequent users of NHS healthcare. The additional cost of training and intervention delivery was deemed minimal in comparison to 'treatment as usual'. Outcome measures of self-harm, quality of life and depression were found to be acceptable.

CONCLUSIONS

The intervention proved feasible to adapt. Staff training was delivered but on the whole it was not deemed feasible for staff to deliver the intervention. A large-scale study is warranted, but modifications to the implementation of the intervention are required.

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

METHODS

In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.

Implementation of a problem-solving training initiative to reduce self-harm in prisons: a qualitative perspective of prison staff, field researchers and prisoners at risk of self-harm

BACKGROUND

Social problem-solving is one technique used to help reduce incidence of self-harm. Our study evaluated the feasibility and acceptability of the adaptation and implementation of a brief Problem-Solving Training (PST) intervention to reduce self-harm in prisons.

METHODS

The process involved i) adaptation of the training materials using focus groups with prison staff and prisoners, ii) training frontline prison staff to use the skills, and iii) implementation of the skills with prisoners at risk of self-harm. Qualitative interviews were conducted with prison staff, prisoners and field researchers and were analysed using a thematic framework to produce a model of the barriers and facilitators to the process.

RESULTS

We conducted 43 interviews across three prison sites. The interviews included 19 prison staff, 18 prisoners and six field researcher meetings. The adaptation to the training and intervention materials were well received. The findings identified the need to support training using a collaborative and flexible approach. Prisoner engagement was affected by their own personal circumstances and by a range of contextual issues relating to the prison environment. Implementation of the skills by prison staff were hindered by resource constraints, the prison environment and staff attitudes.

CONCLUSIONS

We found that it was feasible to adapt an existing intervention and contextualise it within the prison environment. Although we could train large numbers of staff it was deemed unfeasible for staff to implement the problem-solving skills to prisoners at risk of self-harm. Prisoners who engaged with the intervention reported a range of benefits. Alternative implementation mechanisms to tackle the contextual barriers proposed by staff and prisoners included delivery of the intervention using an educational setting and/or use of a prisoner peer-led scheme.

Self-injury: Treatment, Assessment, Recovery (STAR): online intervention for adolescent non-suicidal self-injury - study protocol for a randomized controlled trial

BACKGROUND

Non-suicidal self-injury (NSSI) is a clinically significant behavior affecting approximately 18% of adolescents and young adults worldwide. The importance of NSSI is supported by its association with a broad spectrum of mental disorders. Despite its high relevance, evidence-based, specific, time-, and cost-effective treatment approaches are scarce. Cognitive behavioral therapy (CBT) seems effective in reducing the frequency of NSSI in adolescents and young adults. However, young people are often reluctant to seek professional help and effective interventions adressing NSSI are not sufficiently available across all regions of Germany. Research indicates that the majority of youth with risk behavior (including NSSI) prefer technology-based interventions. To date, effective interventions for adolescents and young adults with NSSI that are deliverd online are not available.

METHODS

The present project aims to develop and evaluate an online intervention for adolescents and young adults with NSSI based on the content of a recently evaluated face-to-face short-term program that includes elements of CBT and dialectical behavior therapy (DBT): "The Cutting Down Programme" (CDP). The efficacy of the new online CDP intervention will be tested in a randomized controlled trial (RCT) in which n = 700 youths engaging in repetitive NSSI will participate in either an online psychoeducation (n = 350) or online CDP (n = 350). Within a postline assessment four months after baseline (end of treatment; T1), and follow-up evaluations 12 and 18 months after baseline (follow-ups; T2 and T3), NSSI and comorbid symptoms as well as quality of life will be assessed. It is hypothesized that participants receiving online CDP report a greater reduction in the frequency of NSSI within the last three months at T2 (primary endpoint) compared to those receiving online psychoeducation. Exploratory analyses will focus on predictors of treatment outcome.

DISCUSSION

We report on the development and evaluation of an online intervention for adolescents and young adults engaging in NSSI based on the CDP. If supported by empirical evidence, an online-based intervention for NSSI might help to overcome the limited availability of adequate interventions for youth.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014623 . Registered on 22 May 2018.

Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: Impact of content and quality on outcomes in a systematic review

BACKGROUND

Randomized controlled trials (RCTs) are the mainstay of evaluations of the efficacy of psychosocial interventions. In a recent Cochrane systematic review we analysed the efficacy of cognitive behavioural-based psychotherapies compared to treatment as usual (TAU) in adults who self-harm. In this study we examine the content and reporting quality of TAU in these trials and their relationship to outcomes.

METHODS

Five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched for RCTs, indexed between 1 January 1998 and 30 April 2015, of cognitive-behavioural interventions compared to TAU for adults following a recent (within six months) episode of self-harm. Comparisons were made between outcomes for trials which included different categories of TAU, which were grouped as: multidisciplinary treatment, psychotherapy only, pharmacotherapy only, treatment by primary care physician, minimal contact, or unclear.

RESULTS

18 trials involving 2433 participants were included. The content and reporting quality of TAU varied considerably between trials. The apparent effectiveness of cognitive behavioural psychotherapy varied according to TAU reporting quality and content. Specifically, effects in favour of cognitive-behavioural psychotherapy were strongest in trials in which TAU content was not clearly described (Odds Ratio: 0.29, 95% Confidence Interval 0.15-0.62; three trials) compared to those in which TAU comprised multidisciplinary treatment (Odds Ratio: 0.79, 95% CI 0.63 to 0.97; 12 trials).

LIMITATIONS

The included trials had high risk of bias with respect to participant and clinical personnel blinding, and unclear risk of bias for selective outcome reporting.

CONCLUSIONS

TAU content and quality represents an important source of heterogeneity between trials of psychotherapeutic interventions for prevention of self-harm. Before clinical trials begin, researchers should plan to carefully describe both aspects of TAU to improve the overall quality of investigations.

Use of Ecological Momentary Assessment (EMA) in Non-Suicidal Self-Injury (NSSI): A systematic review

Conceptualization and assessment of non-suicidal self-injury (NSSI) has evolved substantially in recent years. In both cross-sectional and longitudinal studies, NSSI and its related variables have traditionally been assessed retrospectively, leading to less precise studies of the mechanisms involved in the maintenance, cessation, or aggravation of this behavior. Ecological momentary assessment (EMA) enables real-time collection of patient states, which can be very useful in the study of the mechanisms implied in this behavior. This systematic review aims to elucidate the current status of EMA use in NSSI investigation. An exhaustive search in PubMed and PsycINFO was conducted up to September 2017. All papers included were focused on the study of NSSI using EMA. Studies with methodological diversity were included, which were afterwards organized according to main topic of studies. There were no ineligibility criteria based on age or diagnosis. Twenty-three papers were studied, the majority of which are short-term studies focused on the study of affect dynamics and the emotion-regulation function of NSSI. Implications of these results and recommendations for future research are discussed.

Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning

BACKGROUND

If effective, less intensive treatments for people with personality disorder have the potential to serve more people.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of psychoeducation with problem-solving (PEPS) therapy plus usual treatment against usual treatment alone in improving social problem-solving with adults with personality disorder.

DESIGN

Multisite two-arm, parallel-group, pragmatic randomised controlled superiority trial.

SETTING

Community mental health services in three NHS trusts in England and Wales.

PARTICIPANTS

Community-dwelling adults with any personality disorder recruited from community mental health services.

INTERVENTIONS

Up to four individual sessions of psychoeducation, a collaborative dialogue about personality disorder, followed by 12 group sessions of problem-solving therapy to help participants learn a process for solving interpersonal problems.

MAIN OUTCOME MEASURES

The primary outcome was measured by the Social Functioning Questionnaire (SFQ). Secondary outcomes were service use (general practitioner records), mood (measured via the Hospital Anxiety and Depression Scale) and client-specified three main problems rated by severity. We studied the mechanism of change using the Social Problem-Solving Inventory. Costs were identified using the Client Service Receipt Inventory and quality of life was identified by the European Quality of Life-5 Dimensions questionnaire. Research assistants blinded to treatment allocation collected follow-up information.

RESULTS

There were 739 people referred for the trial and 444 were eligible. More adverse events in the PEPS arm led to a halt to recruitment after 306 people were randomised (90% of planned sample size); 154 participants received PEPS and 152 received usual treatment. The mean age was 38 years and 67% were women. Follow-up at 72 weeks after randomisation was completed for 62% of participants in the usual-treatment arm and 73% in the PEPS arm. Intention-to-treat analyses compared individuals as randomised, regardless of treatment received or availability of 72-week follow-up SFQ data. Median attendance at psychoeducation sessions was approximately 90% and for problem-solving sessions was approximately 50%. PEPS therapy plus usual treatment was no more effective than usual treatment alone for the primary outcome [adjusted difference in means for SFQ -0.73 points, 95% confidence interval (CI) -1.83 to 0.38 points; p = 0.19], any of the secondary outcomes or social problem-solving. Over the follow-up, PEPS costs were, on average, £182 less than for usual treatment. It also resulted in 0.0148 more quality-adjusted life-years. Neither difference was statistically significant. At the National Institute for Health and Care Excellence thresholds, the intervention had a 64% likelihood of being the more cost-effective option. More adverse events, mainly incidents of self-harm, occurred in the PEPS arm, but the difference was not significant (adjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.64).

LIMITATIONS

There was possible bias in adverse event recording because of dependence on self-disclosure or reporting by the clinical team. Non-completion of problem-solving sessions and non-standardisation of usual treatment were limitations.

CONCLUSIONS

We found no evidence to support the use of PEPS therapy alongside standard care for improving social functioning of adults with personality disorder living in the community.

FUTURE WORK

We aim to investigate adverse events by accessing centrally held NHS data on deaths and hospitalisation for all PEPS trial participants.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN70660936.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 52. See the NIHR Journals Library website for further project information.

Psychological treatment for personality disorders

There is encouraging evidence that some patients with personality disorder are treatable. Psychotherapeutic interventions show promise, although interpretation of the literature is problematic: the number of patients in most trials is small, outcome measures are questionable, follow-up is limited, and treatments are multifaceted, complex interventions in which the effective components are unclear. The evidence base can be assessed according to efficacy and generalisability, and when both are taken into account the best verification is for psychodynamic therapy. However, there is inadequate evidence to make specific recommendations for any particular therapy.

Treatment of personality disorder: skills-based therapies

A variety of therapies have been developed or adapted to treat personality disorder over recent years. This article will review skills-based treatments (as opposed to insight-based treatments). Two approaches are outlined: cognitive-behavioural therapy and dialectical behaviour therapy. The article details the underpinning theory and the model of personality disorder utilised by the two approaches, and describes how the therapy is applied. Evidence of therapeutic efficacy is presented along with information about accessing training and therapy materials.

Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: a feasibility study

BACKGROUND

Nonsuicidal self-injury (NSSI) is a serious health risk behavior that forms the basis of a tentative diagnosis in DSM-5, NSSI Disorder (NSSID). To date, established treatments specific to NSSI or NSSID are scarce. As a first step in evaluating the feasibility, acceptability, and utility of a novel treatment for adolescents with NSSID, we conducted an open trial of emotion regulation individual therapy for adolescents (ERITA): a 12-week, behavioral treatment aimed at directly targeting both NSSI and its proposed underlying mechanism of emotion regulation difficulties.

METHODS

Seventeen girls (aged 13-17; mean = 15.31) with NSSID were enrolled in a study adopting an uncontrolled open trial design with self-report and clinician-rated assessments of NSSI and other self-destructive behaviors, emotion regulation difficulties, borderline personality features, and global functioning administered at pre-treatment, post-treatment, and 6-month follow-up. Measures of NSSI and emotion regulation difficulties were also administered weekly during treatment.

RESULTS

Ratings of treatment credibility and expectancy and the treatment completion rate (88%) were satisfactory, and both therapeutic alliance and treatment attendance were strong. Intent-to-treat analyses revealed significant improvements associated with large effect sizes in past-month NSSI frequency, emotion regulation difficulties, self-destructive behaviors, and global functioning, as well as a medium effect size in past-month NSSI versatility, from pre- to post-treatment. Further, all of these improvements were either maintained or further improved upon at 6-month follow-up. Finally, change in emotion regulation difficulties mediated improvements in NSSI over the course of treatment.

CONCLUSIONS

Results suggest the acceptability, feasibility, and utility of this treatment for adolescents with NSSID.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02326012, December 22, 2014, retrospectively registered).

An intervention for nonsuicidal self-injury in young adults: A pilot randomized controlled trial

OBJECTIVE

Nonsuicidal self-injury (NSSI) is prevalent among young adults and associated with negative medical and psychological consequences, necessitating its treatment. However, few treatments have been developed to treat NSSI specifically, or to treat the behavior among individuals without borderline personality disorder. The purpose of this study was to investigate the Treatment for Self-Injurious Behaviors (T-SIB), a brief, behavioral intervention specifically developed to treat NSSI among young adults, in a pilot randomized controlled trial (RCT).

METHOD

Young adults (N = 33; age: M = 22.36 years, SD = 3.40) meeting inclusion and exclusion criteria were randomly assigned to the treatment (T-SIB; n = 15) or treatment as usual (n = 18) condition. The sample was 93.9% female, 42.4% Caucasian, and 30.3% Hispanic/Latino.

RESULTS

Feasibility and acceptability of the study and intervention were supported, and medium effects were found for decreased NSSI frequency in the T-SIB group using intent-to-treat analyses.

CONCLUSION

Results of this study support the further evaluation of T-SIB in a larger RCT. (PsycINFO Database Record

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Effective psychological and psychosocial approaches to reduce repetition of self-harm: a systematic review, meta-analysis and meta-regression

OBJECTIVE

To examine the efficacy of psychological and psychosocial interventions for reductions in repeated self-harm.

DESIGN

We conducted a systematic review, meta-analysis and meta-regression to examine the efficacy of psychological and psychosocial interventions to reduce repeat self-harm in adults. We included a sensitivity analysis of studies with a low risk of bias for the meta-analysis. For the meta-regression, we examined whether the type, intensity (primary analyses) and other components of intervention or methodology (secondary analyses) modified the overall intervention effect.

DATA SOURCES

A comprehensive search of MEDLINE, PsycInfo and EMBASE (from 1999 to June 2016) was performed.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of psychological and psychosocial interventions for adult self-harm patients.

RESULTS

Forty-five trials were included with data available from 36 (7354 participants) for the primary analysis. Meta-analysis showed a significant benefit of all psychological and psychosocial interventions combined (risk ratio 0.84; 95% CI 0.74 to 0.96; number needed to treat=33); however, sensitivity analyses showed that this benefit was non-significant when restricted to a limited number of high-quality studies. Meta-regression showed that the type of intervention did not modify the treatment effects.

CONCLUSIONS

Consideration of a psychological or psychosocial intervention over and above treatment as usual is worthwhile; with the public health benefits of ensuring that this practice is widely adopted potentially worth the investment. However, the specific type and nature of the intervention that should be delivered is not yet clear. Cognitive-behavioural therapy or interventions with an interpersonal focus and targeted on the precipitants to self-harm may be the best candidates on the current evidence. Further research is required.

Psychological interventions for post-traumatic stress disorder in people living with HIV in Resource poor settings: a systematic review

OBJECTIVE

Post-traumatic stress disorder is pervasive in low- and middle-income countries. There is evidence to suggest that post-traumatic stress disorder is more common among people living with HIV than non-infected matched controls. We carried out a systematic review of interventions for adult post-traumatic stress disorder from resource poor settings with a focus on people living with HIV.

METHODS

We included all studies that investigated interventions for adult post-traumatic stress disorder from resource poor settings with a focus on interventions that were either randomised controlled trials or observational cohort studies carried out from 1980 to May 2015.

RESULTS

Of the 25 articles that were identified for full review, two independent reviewers identified seven studies that met our study inclusion criteria. All randomised controlled trials (RCT) (n = 6) used cognitive behavioural therapy-based interventions and focused on people living with HIV in resource poor settings. There was only one study focusing on the use of lay counsellors to address post-traumatic stress disorder but core competencies were not described. There were no intervention studies from Africa, only an observational cohort study from Rwanda.

CONCLUSION

Rigorously evaluated interventions for adult post-traumatic stress disorder in people living with HIV are rare. Most were undertaken in resource poor settings located in high-income countries. There is a need for research on the development and implementation of appropriate interventions for post-traumatic stress disorder in people living with HIV in low- and middle-income countries.

Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis

BACKGROUND

Self-harm (intentional acts of non-fatal self-poisoning or self-injury) is common, particularly in young adults aged 15-35 years, often repeated, and strongly associated with suicide. Effective aftercare of individuals who self-harm is therefore important. We have undertaken a Cochrane systematic review and meta-analysis of the effectiveness of psychosocial interventions for self-harm in adults.

METHODS

We searched five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, Embase, and PsycINFO) between Jan 1, 1998, and April 29, 2015, for randomised controlled trials of psychosocial interventions for adults after a recent (within 6 months) episode of self-harm. Most interventions were assessed in single trials. We report results for interventions for which at least three randomised controlled trials comparing interventions with treatment as usual have been published and hence might contribute to clinical guidance. The primary outcome was repetition of self-harm at the conclusion of treatment and at 6, 12, and 24 months' follow-up analysed, when available, with the intention-to-treat method; if this was not possible, we analysed with all available case data.

FINDINGS

We identified 29 non-overlapping randomised controlled trials with three independent trials of the same intervention. Cognitive-behavioural-based psychotherapy (CBT; comprising cognitive-behavioural and problem-solving therapy) was associated with fewer participants repeating self-harm at 6 months' (odds ratio 0·54, 95% CI 0·34-0·85; 12 trials; n=1317) and at 12 months' follow-up (0·80, 0·65-0·98; ten trials; n=2232). There were also significant improvements in the secondary outcomes of depression, hopelessness, suicidal ideation, and problem solving. Patients receiving dialectical behaviour therapy (in three trials) were not less likely to repeat self-harm compared with those provided with treatment as usual at 6 months (odds ratio [OR] 0·59, 95% CI 0·16-2·15; n=267, three trials) or at 12 months (0·36, 0·05-2·47; n=172, two trials). However, the secondary endpoint of frequency of self-harm was associated with a significant reduction with use of dialectical behaviour therapy (mean difference -18·82, 95% CI -36·68 to -0·95). Four trials each of case management (OR 0·78, 95% CI 0·47-1·30; n=1608) and sending regular postcards (OR 0·87, 95% CI 0·62-1·23; n=3277) did not reduce repetition of self-harm.

INTERPRETATION

CBT seems to be effective in patients after self-harm. Dialectical behaviour therapy did not reduce the proportion of patients repeating self-harm but did reduce the frequency of self-harm. However, aside from CBT, there were few trials of other promising interventions, precluding firm conclusions as to their effectiveness.

FUNDING

National Institute for Health Research.

EMDR in the Treatment of Borderline Personality Disorder

Individuals diagnosed with borderline personality disorder (BPD) usually experience significant impairment in their ability to function. Impulsivity, affect instability, interpersonal difficulties, and identity problems are hallmark features of this disorder, frequently leading to suicidal and parasuicidal behaviors. Although BPD has traditionally been considered chronic and enduring, recent research has indicated that it can remit over time and that psychotherapy can accelerate this process. The etiology of BPD has been associated with childhood abuse and inadequate attachment. Given the significance of childhood abuse and trauma, eye movement desensitization and reprocessing (EMDR), a recognized trauma therapy, may be a reasonable treatment option for BPD. The positive effects noted in the following case illustrate EMDR’s utility in the treatment of BPD and indicate that further controlled studies are warranted.

MEDIACONNEX: a multicenter randomised trial based on short message service to reduce suicide attempt recurrence in adolescents

BACKGROUND

Suicide attempt among adolescents is a public health problem around the world. The risk of recurrence is high: about 30 % of adolescents. New ways to prevent suicide attempt recurrence being developed for adult suicide attempters include maintaining contact with them, and results are encouraging.

METHODS/DESIGN

The MEDIACONNEX study will be a simple blinded, parallel-group, multicenter randomised controlled trial. It will compare usual care alone to a program based on usual care plus short message service (SMS) provided to adolescents who attempt suicide and who receive treatment in pediatric and adolescent psychiatry units at hospitals in eastern France. Adolescents will be recruited over an 18-month period. The intervention will be based on the SMS, involving personalized and evolving text messages, sent on days 7 to 14 and months 1, 2, 4 and 6 after the SA. The primary endpoint will be the recurrence of an SA, with an assessment during 12 months. Secondary endpoints will be the evolution of 1) social networks, 2) depression and 3) health-related quality of life, with an assessment at inclusion and at 6 months.

DISCUSSION

This paper describes the design of MEDIACONNEX, which will assess the effectiveness of an SMS program for adolescent suicide attempters on SA recurrence. This program will be easy to reproduce and inexpensive.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (no. NCT02762734 ) on March 2016.

Suicide

Suicide is a major mental health problem in the United States and an issue that significantly impacts the mental health treatment community. Although the suicide rate remains relatively stable, the discipline of counseling psychology has broadened in scope and work settings have diversified. Thus, counseling psychology trainees are increasingly exposed to suicidal clients. Despite this reality, research suggests that comprehensive, systematic training in suicidology in counseling psychology programs rarely occurs. One reason for this state of affairs may be that the suicide literature is spread across a variety of disciplines, making it difficult for educators and practitioners to stay informed about the knowledge base in suicidology. The purpose of this contribution, therefore, is to provide counseling psychology educators and practitioners with an overview of the field of suicidology as it applies to the training and practice of counseling psychology.

Psychosocial interventions for self-harm in adults

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

OBJECTIVES

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures.

MAIN RESULTS

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

AUTHORS' CONCLUSIONS

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.

Suicide, Suicide Attempts, and Suicidal Ideation

Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. One key development is the ideation-to-action framework, which stipulates that (a) the development of suicidal ideation and (b) the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. For example, it is becoming clear that depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. Means restriction is also emerging as a highly effective way to block progression from ideation to attempt. A third key development is the proliferation of theories of suicide that are positioned within the ideation-to-action framework. These include the interpersonal theory, the integrated motivational-volitional model, and the three-step theory. These perspectives can and should inform the next generation of suicide research and prevention.

Models of correction and prevention of self-injurious behavior

We present a review of models of correction of self-injurious and suicidal behavior. Cognitive-behavioral approach includes cognitive-behavioral therapy, acceptance-based group therapy focused on enhancing emotional regulation and rising emotional aware- ness, dialectical behavioral therapy directed at rising emotional awareness, improving in- terpersonal relationships and teaching adaptive ways of coping with emotions, functional analysis and functional communication training. Psychodynamic approach includes mentalized-based treatment, transference-focused psychotherapy, psychoanalytic psychotherapy, and cognitive-analytic therapy. Model of family therapy based on theory of attachment and multilevel model of intervention are considered. We discuss general and specific aspects of prevention of self-injury in clinical and normal populations. Requirements for the development of self-injury prevention programs for schools are listed.

Development of an Intervention for Nonsuicidal Self-Injury in Young Adults: An Open Pilot Trial

Nonsuicidal self-injury (NSSI) is a prevalent and dangerous behavior among young adults, but no treatments specific to NSSI have been developed for patients without borderline personality disorder. The purpose of this study was to develop and investigate a novel intervention for NSSI among young adults. The intervention is a 9-session behavioral treatment designed to decrease the frequency of NSSI behaviors and urges. Using an open pilot design, feasibility and acceptability were investigated in a small sample (n = 12) over a 3-month follow-up period. A preliminary investigation of change in NSSI was also conducted. Feasibility and acceptability of the intervention were supported. Medium to large effect sizes were found for decreases in NSSI behaviors and urges over the follow-up period. Results of this open pilot trial support the further evaluation of this intervention.

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.

Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions

OBJECTIVE

Nonsuicidal self-injury (NSSI), the deliberate, self-inflicted damage of bodily tissue without the intent to die, is associated with various negative outcomes. Although basic and epidemiologic research on NSSI has increased during the last 2 decades, literature on effective interventions targeting NSSI is still emerging. Here, we present a comprehensive, systematic review of existing psychological and pharmacological treatments designed specifically for NSSI, or including outcome assessments examining change in NSSI.

METHOD

We conducted a systematic search of PsycINFO, MEDLINE, and ERIC databases to retrieve relevant articles that met inclusion criteria; specifically, uncontrolled and controlled trials that 1) presented quantitative outcome data on NSSI, and 2) clearly differentiated NSSI from suicidal self-injury (SSI). Consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, definition of NSSI, we excluded studies examining populations with developmental or intellectual disabilities, or with psychotic disorders.

RESULTS

Several interventions appear to hold promise for reducing NSSI, including dialectical behaviour therapy, emotion regulation group therapy, manual-assisted cognitive therapy, dynamic deconstructive psychotherapy, atypical antipsychotics (aripiprazole), naltrexone, and selective serotonin reuptake inhibitors (with or without cognitive-behavioural therapy). Nevertheless, there remains a paucity of well-controlled studies investigating treatment efficacy for NSSI.

CONCLUSIONS

Structured psychotherapeutic approaches focusing on collaborative therapeutic relationships, motivation for change, and directly addressing NSSI behaviours seem to be most effective in reducing NSSI. Medications targeting the serotonergic, dopaminergic and opioid systems also have demonstrated some benefits. Future studies employing controlled designs as well as a clear delineation of NSSI and SSI will improve knowledge regarding treatment effects.

Suicidal behaviour and cognitive problem solving therapy: theory, application and review

Suicidal behaviour is a major public health problem worldwide, both with regard to mortality and treatment of clients who have deliberately harmed themselves. It is a multifaceted problem resulting from complex interactions between social, biological and psychological factors. There is insufficient evidence on which to make firm recommendations about the most effective forms of treatment This is remarkable considering the extent of the problem worldwide, and the importance of dealing with it appropriately in order to prevent further suicides.

An evaluation of a collaborative bibliotherapy scheme delivered via a library service

This paper reports on the evaluation of a bibliotherapy scheme delivered via a local library service, in conjunction with General Practice (GP) practices, local social welfare agencies and through self-referral. The Read Yourself Well (RYW) scheme was based on principles established from other similar schemes and as a way of delivering support for adults experiencing mild to moderate mental health problems for whom clinical treatments are not appropriate. The intervention consisted of initial referral and evaluation by the scheme bibliotherapist, a one-hour session at the beginning and end of the intervention where a purpose-designed questionnaire and two mental health assessments were carried out (the General Health Questionnaire and the Clinical Outcomes in Routine Evaluation questionnaire). Contact and support from the bibliotherapist was provided during the intervention period. One hundred and fifty-seven participants were recruited to the evaluation of whom 114 provided full data. Statistical analyses of the mental health scores showed significant improvements post treatment, for, both male and female participants, for all three referral routes, and for participants who were previously library users, and those who joined the library service to participate in the RYW scheme. The results of this large sample evaluation support the proposal that library-based bibliotherapy can be effective in the treatment of mental health problems.

Short-term psychotherapeutic treatment in adolescents engaging in non-suicidal self-injury: a randomized controlled trial

Background

Worldwide, prevalence rates of adolescent non-suicidal self-injury (NSSI) range between 13 and 45%. In Germany, lifetime prevalence of NSSI is around 25% in non-clinical samples, and the one-year prevalence for repetitive NSSI is 4%. NSSI is present in the context of several axis I and II disorders (for example, affective disorders or borderline personality disorder); however, preliminary evidence suggests that it would be justified to consider NSSI as its own diagnostic category. Despite the large impact of this behavior, there is still a lack of evidence-based, specific, and effective manualized treatment approaches for adolescents with NSSI.

Methods/Design

The study is designed as a randomized controlled trial (RCT) to test the effectiveness of a new cognitive-behavioral treatment manual for self-harming adolescents - the ‘Cutting-Down-Programme’ (CDP). A total of 80 adolescents aged between 12 and 17 years from a region in Southern Germany who have engaged in repetitive NSSI (≥5 incidents) in the last 6 months will be randomized into a treatment group (CDP) or a control group that will receive treatment as usual (TAU). The adolescents will be assessed by means of structured interviews and questionnaires at three time points (before treatment, directly after treatment and six months after treatment). Primary outcome criterion is a significant reduction (or remission) in the frequency of NSSI. Secondary outcome criteria are depressivity as well as general well-being and self-worth. Additionally, comorbid psychiatric disorders and childhood adversity will be evaluated as predictors of therapeutic outcome.

Discussion

Recently, a pilot study in the United Kingdom showed significant reductions in self-harming behavior, depressive symptoms and trait anxiety. This is the first RCT to test the effectiveness of a short-term psychotherapeutic intervention in outpatients engaging in NSSI.

Trial registration

The study is registered in the German Clinical Trials Register DRKS00003605.

A Proof of Concept for Using Brief Dialectical Behavior Therapy as a Treatment for Problem Gambling

Fourteen ‘treatment resistant’ problem gamblers received 9 weeks of Dialectical Behavior Therapy (DBT) at specialist problem gambling services delivered in Melbourne, Australia. This study is the first to investigate the effectiveness of a brief DBT treatment for problem gambling, with a focus on measuring change in the four DBT process skills (mindfulness, distress tolerance, emotion dysregulation, and negative relationships). Although there were no statistically significant improvements in measures of gambling behaviour, 83% of participants were abstinent or reduced their gambling expenditure pre- to post-treatment. Participants also reported statistically and clinically significant improvements in psychological distress, mindfulness, and distress tolerance. Moreover, there were no increases in alcohol or substance use. These results are discussed in the context of focusing on a single DBT process skill, and the benefits of using group-based approaches.

Moving beyond specialized therapies for borderline personality disorder: the importance of integrated domain-focused treatment

This article argues the recent emphasis on specializing treatments for borderline personality disorder needs to be replaced by a more integrated and evidence-based approach that combines effective methods from all therapies. This proposition is based on evidence that specialized treatments for borderline personality disorder do not differ significantly from each and that they are not more effective than good structured care designed to meet the needs of patients with the disorder. It is also argued that current therapies are limited because they do not recognize or accommodate the extensive heterogeneity of borderline personality disorder and its complex etiology. These factors make a one-approach-fits-all strategy inappropriate for treatment. An integrated approach is proposed as an alternative to the specialized therapies that makes use of all effective interventions regardless of their conceptual origins and delivers them in a coordinated way. A two-component framework is proposed for organizing integrated treatment: 1. a system for conceptualizing borderline personality disorder based on current empirical knowledge about the structure, etiology, and stability of borderline pathology that serves as a guide when selecting and delivering interventions; and 2. a model of therapeutic change based on the general literature on psychotherapy outcome and specific studies of PD treatments. This framework proposes that integrated treatment be organized around principles of therapeutic change common to all effective therapies supplemented with more specific treatment methods taken from the different therapies as needed to tailor treatment to individual patients and treat specific problems and psychopathology.