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

Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care

BACKGROUND

Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care.

METHODS

Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses.

RESULTS

There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history).

CONCLUSION

The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

Interventions for youth suicide and suicide-related behaviour: An update to a systematic review

OBJECTIVE

To update our 2018 review with the latest evidence from randomised controlled trials (RCTs) on the effectiveness of interventions to prevent youth suicide and suicide-related behaviour.

METHOD

In keeping with our 2018 review, Embase, PsycInfo, and Medline were searched using relevant key words. Included trials were RCTs evaluating the impact of an intervention or approach designed to prevent or reduce youth suicide and suicide-related behaviour. Key data were extracted, and results synthesised narratively.

RESULTS

Thirty RCTs were included across clinical (n = 13), educational (n = 8), and community settings (n = 9). No trials were conducted in workplace or primary care settings, or with indigenous populations, and few trials involved partnerships with young people. There were some concerns or a high risk of bias for most trials.

CONCLUSION

While a relatively large number of RCTs have been published in recent years, knowledge gaps remain. Further high-quality RCTs are needed, including those focussing on vulnerable population groups. Meaningful consumer involvement and a stronger emphasis on implementation are also recommended.

A meta-analysis of targeted interventions for reducing suicide-related behaviour and ideation in adolescents: Implications for trial design

INTRODUCTION

Suicidality among young people is a significant societal issue. The current study conducted a meta-analysis of community and clinical interventions targeting suicide attempts, self-harm, and suicidal ideation in adolescents.

METHODS

Interventions targeting suicide attempts, self-harm and suicidal ideation were identified by searching PsychINFO, Medline, CINAHL and Embase in line with the PRISMA statement. Study quality was determined using a risk of bias tool. Meta-analyses examined the efficacy of the interventions. Effect sizes were calculated for suicidal ideation data (continuous data) using Hedge's g for standardised mean differences. Suicide attempts and self-harm (dichotomous data) were calculated using odds ratios (ORs).

RESULTS

Seventeen RCTs were included in the meta-analysis. No significant differences were found between treatment and control groups on measures of suicide attempts or self-harm. A small effect-size was observed on measures of suicidal ideation (g = 0.47). A secondary meta-analysis investigated change over time in treatment as usual conditions, finding significant large effect-sizes for suicide attempts (OR = 18.67), self-harm (OR = 12.77), and suicidal ideation (g = 0.86).

LIMITATIONS

The methodological decision to focus on specific outcomes over a broad definition of self-harm excluded some papers, which have been included in other reviews. It is unlikely to have significantly affected the overall results. The review was not preregistered.

CONCLUSIONS

These twin findings highlight the importance overcoming the methodological difficulty of discerning effective interventions during a period of baseline improvement. We suggest that future trials should move away from broadly addressing "suicidality/self-harm" and encourage a greater targeting of at-risk individuals.

Effect of alcohol interventions on suicidal ideation and behaviour: A systematic review and meta-analysis

BACKGROUND

Alcohol consumption is related to both suicidal ideation and behaviour, but evidence regarding the effect of psychological interventions to reduce alcohol use on self-harm, suicidal behaviour and ideation is limited. Therefore, the aim of the current study was to conduct a systematic literature review and meta-analysis of the effect of alcohol-related psychological interventions on these outcomes at the individual level.

METHODS

We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases to 5 January 2021. We included all English-language papers worldwide utilising psychological interventions with a focus on harmful alcohol use and suicidal ideation, self-harm, and/or suicidal behaviour.

RESULTS

We identified 11 studies, nine provided sufficient numerical data for meta-analysis. Although the methods and effect sizes varied substantially in the studies, reducing alcohol may led to a reduction in self-harm and suicide attempt by the final follow-up assessment (Odds ratio [OR] 0.57, 95% confidence interval [CI] 0.33 to 0.97, 6 studies, 491 participants, I² = 0%). However, there was no apparent effect for these interventions on suicidal ideation or suicide deaths. There was no significant difference in effect by therapeutic approach. Neither intervention dose (in hours) nor duration (in months) significantly explained differences in treatment effectiveness.

CONCLUSIONS

Interventions targeting harmful alcohol consumption may contribute towards a reduction in self-harm at the individual level. However, there was no apparent effect of these interventions on suicidal ideation (measured either continuously or dichotomously) or suicide deaths.

Study designs and outcomes used in evaluation studies of hospital-presenting self-harm: protocol for a methodological systematic review

INTRODUCTION

Self-harm is the most common risk factor for suicide, and so those who present to hospital following self-harm provide an opportunity for targeted clinical care interventions. Observational studies evaluating such interventions may be useful in overcoming limitations of controlled trials, but study design, statistical analyses and outcomes used must be appropriate. This methodological systematic review will describe, categorise, synthesise and compare the methodological aspects of studies evaluating interventions and aspects of clinical management following hospital-presenting self-harm in both observational and experimental (ie, controlled trials or quasi-experimental studies) study designs.

METHODS AND ANALYSIS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocol guidelines were followed in drafting this protocol. Search terms were developed (related to self-harm, hospital presentation and evaluation studies) and adapted for MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and grey literature databases. Two reviewers will independently screen 100 titles/abstracts until consensus is reached, with the remaining screened by one reviewer. Full-text screening will be conducted independently by two reviewers. Data will be extracted by one reviewer, and a second will check all data extracted. Validated risk of bias tools will be used. Data synthesis will focus on the heterogeneity of outcomes used in individual studies. Descriptive summary statistics of the data (eg, key study characteristics, type and frequency of outcomes) will be provided in categorical format, using frequencies and percentages. Outcomes will be reported separately for trials (both randomised and non-randomised trials), observational and quasi-experimental studies. Categorisation of outcomes will be guided by Cochrane Effective Practice and Organisation of Care resources for reviews of health systems interventions.

ETHICS AND DISSEMINATION

Results will be disseminated at national and international conferences and published in a peer-reviewed journal. Findings will be used to inform future studies in the area of hospital-presenting self-harm. Ethical approval is not required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208714.

Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomised controlled trial of cognitive behavioural therapy plus fluoxetine in young people

OBJECTIVES

Effective treatment of depression is a key target for suicide prevention strategies. However, only around one-third of young people with suicide risk respond to evidence-based treatments. Understanding the trajectory of suicidal ideation, as a marker of suicide risk, over the course of evidence-based treatment for depression might provide insight into more targeted and effective treatments.

METHODS

This is a secondary analysis of data from the multicentre Youth Depression Alleviation-Combined Treatment trial. A total of 153 young people aged 15-25 years diagnosed with major depressive disorder were randomly assigned in this double-blind, placebo-controlled trial to either cognitive behavioural therapy plus fluoxetine or cognitive behavioural therapy plus placebo. Participants were assessed for depression and suicidal ideation at baseline and at weeks 4, 8 and 12.

RESULTS

Using group-based trajectory modelling, we identified two distinct depression trajectories. The first (Improving; 54.9%; n = 83) comprised those who experienced a consistent decline in depression symptoms. The second (Persisting; 45.1%; n = 70) comprised those who, despite treatment, still had clinically significant levels of depression by the end of treatment. For suicidal ideation, we identified four distinct trajectories: Non-clinical (15.5%; n = 20), Low Improving (47.1%; n = 75), High Improving (24.8%; n = 38) and High Persisting (12.7%; n = 20). Treatment allocation was not significantly associated with trajectory membership for either depression or suicidal ideation.

CONCLUSION

Understanding the course of depression and suicidal ideation during treatment has important implications for managing suicide risk. The findings suggest that there is an identifiable group of young people for whom enhanced psychological and/or pharmacological intervention might be required to ensure a better treatment response. Specific interventions for those with suicidal ideation may also be prudent from the outset.

CLINICAL TRIAL REGISTRATION

The Youth Depression Alleviation-Combined Treatment trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12612001281886).

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.

Interventions for self-harm in children and adolescents

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 countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.

OBJECTIVES

To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialized 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 specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents 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 ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) 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 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments.

AUTHORS' CONCLUSIONS

Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.

The effect of a peer-led problem-support mentor intervention on self-harm and violence in prison: An interrupted time series analysis using routinely collected prison data

BACKGROUND

Levels of mental disorder, self-harm and violent behaviour are higher in prisons than in the community. The purpose of this study was to determine whether a brief peer-led problem-support mentor intervention could reduce the incidence of self-harm and violence in an English prison.

METHODS

An existing intervention was adapted using a theory of change model and eligible prisoners were trained to become problem-support mentors. Delivery of the intervention took two forms: (i) promotion of the intervention to fellow prisoners, offering support and raising awareness of the intervention but not delivering the skills and (ii) delivery of the problem-solving therapy skills to selected individual prisoners. Training and intervention adherence was measured using mentor log books. We used an Interrupted Time Series (ITS) design utilizing prison data over a 31 month period. Three ITS models and sensitivity analyses were used to address the impact across the whole prison and in the two groups by intervention delivery. Outcomes included self-harm and violent behaviour. Routine data were collected at monthly intervals 16 months pre-, 10 months during and six months post-intervention. Qualitative data measured the acceptability, feasibility, impact and sustainability of the intervention. A matched case-control study followed people after release to assess the feasibility of formal evaluation of the impact on re-offending up to 16 months.

FINDINGS

Our causal map identified that mental health and wellbeing in the prison were associated with environmental and social factors. We found a significant reduction in the incidence of self-harm for those receiving the full problem-solving therapy skills. No significant reduction was found for incidence of violent behaviour.

INTERPRETATION

Universal prison-wide strategies should consider a series of multi-level interventions to address mental health and well-being in prisons.

FUNDING

Research Champions Fund and the Economic and Social Research Council Impact Acceleration Account Fund, University of York, UK.

Pharmacological 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 countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of pharmacological agents and/or natural products in the treatment of SH is lacking, especially when compared with the evidence for psychosocial interventions. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of pharmacological interventions for SH in adults.

OBJECTIVES

To assess the effects of pharmacological agents or natural products for SH compared to comparison types of treatment (e.g. placebo or alternative pharmacological treatment) 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 pharmacological agents or natural products with placebo/alternative pharmacological treatment in individuals 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 acceptability, 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 ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CI. The overall certainty 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 seven trials with a total of 574 participants. Participants in these trials were predominately female (63.5%) with a mean age of 35.3 years (standard deviation (SD) 3.1 years). It is uncertain if newer generation antidepressants reduce repetition of SH compared to placebo (OR 0.59, 95% CI 0.29 to 1.19; N = 129; k = 2; very low-certainty evidence). There may be a lower rate of SH repetition for antipsychotics (21%) as compared to placebo (75%) (OR 0.09, 95% CI 0.02 to 0.50; N = 30; k = 1; low-certainty evidence). However, there was no evidence of a difference between antipsychotics compared to another comparator drug/dose for repetition of SH (OR 1.51, 95% CI 0.50 to 4.58; N = 53; k = 1; low-certainty evidence). There was also no evidence of a difference for mood stabilisers compared to placebo for repetition of SH (OR 0.99, 95% CI 0.33 to 2.95; N = 167; k = 1; very low-certainty evidence), or for natural products compared to placebo for repetition of SH (OR 1.33, 95% CI 0.38 to 4.62; N = 49; k = 1; lo- certainty) evidence.

AUTHORS' CONCLUSIONS

Given the low or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding pharmacological interventions in patients who engage in SH. More and larger trials of pharmacotherapy are required, preferably using newer agents. These might include evaluation of newer atypical antipsychotics. Further work should also include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.