Postcards, green cards and telephone calls: therapeutic contact with individuals following self-harm

Combining green cards, telephone calls and postcards into an intervention algorithm to reduce suicide reattempt (AlgoS): P-hoc analyses of an inconclusive randomized controlled trial

BACKGROUND

Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.

METHODS

AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.

RESULTS

1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.46 [0.25-0.85] and 0.50 [0.31-0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.84 [0.57-1.25] and 1.00 [0.73-1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.

CONCLUSIONS

This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.

Combining green cards, telephone calls and postcards into an intervention algorithm to reduce suicide reattempt (AlgoS): P-hoc analyses of an inconclusive randomized controlled trial

BACKGROUND

Brief contact interventions (BCIs) might be reliable suicide prevention strategies. BCI efficacy trials, however, gave equivocal results. AlgoS trial is a composite BCI that yielded inconclusive results when analyzed with Intention-To-Treat strategy. In order to elicit intervention strengths and weaknesses, post-hoc analyses of AlgoS data were performed.

METHODS

AlgoS was a randomized controlled trial conducted in 23 French hospitals. Suicide attempters were randomly assigned to either the intervention group (AlgoS) or the control group (Treatment as usual TAU). In the AlgoS arm, first-time suicide attempters received crisis cards; non first-time suicide attempters received a phone call, and post-cards if the call could not be completed, or if the participant was in crisis and/or non-compliant with the post-discharge treatment. An As Treated strategy, accounting for the actual intervention received, was combined with subgroup analyses.

RESULTS

1,040 patients were recruited and randomized into two groups of N = 520, from which 53 withdrew participation; 15 were excluded after inclusion/exclusion criteria reassessment. AlgoS first attempters were less likely to reiterate suicide attempt (SA) than their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.46 [0.25-0.85] and 0.50 [0.31-0.81] respectively). AlgoS non-first attempters had similar SA rates as their TAU counterparts at 6 and 13-14 months (RR [95% CI]: 0.84 [0.57-1.25] and 1.00 [0.73-1.37] respectively). SA rates were dissimilar within the AlgoS non-first attempter group.

CONCLUSIONS

This new set of analysis suggests that crisis cards could be efficacious to prevent new SA attempts among first-time attempters, while phone calls were probably not significantly efficacious among multi-attempters. Importantly, phone calls were informative of new SA risk, thus a key component of future interventions.

Using photo-elicitation to understand reasons for repeated self-harm: a qualitative study

BACKGROUND

Reasons for self-harm are not well understood. One of the reasons for this is that first-hand accounts are usually elicited using traditional interview and questionnaire methods. This study aims to explore the acceptability of using an approach (photo-elicitation) that does not rely on solely verbal or written techniques, and to make a preliminary assessment of whether people can usefully employ images to support a discussion about the reasons why they self-harm.

METHOD

Interviews with eight participants using photo elicitation, a method in which photographs produced by the participant are used as a stimulus and guide within the interview.

RESULTS

Participants responded positively to using images to support a discussion about their self-harm and readily incorporated images in the interview. Four main themes were identified representing negative and positive or adaptive purposes of self-harm: self-harm as a response to distress, self-harm to achieve mastery, self-harm as protective and self-harm as a language or form of communication.

CONCLUSIONS

Employing this novel approach was useful in broadening our understanding of self-harm.

Improving patient care after a suicide attempt

OBJECTIVES

Improving the care that patients receive after a suicide attempt will reduce the risk of a subsequent suicide attempt. We described how care for these patients can be improved and identified the available guidelines.

METHODS

We reviewed the literature on crisis and aftercare, psychosocial assessment, risk assessment, brief contact interventions, and brief interventions.

RESULTS

People who have made a suicide attempt are at increased risk of suicide, and the period immediately after discharge from hospital is particularly risky. Patients require an empathic response at their first point of contact, comprehensive psychosocial assessment, effective discharge planning, rapid and assertive follow-up, and coordinated care in the subsequent months.

CONCLUSIONS

Empathic and effective care that begins in the emergency department and extends through to community care is imperative. Enough is known about the risks of inadequate care and the key ingredients of effective care to proceed with changes to Australia's healthcare response to a suicide attempt.

Online discussion forums for young people who self-harm: user views

Aims and method

To explore what young people who self-harm think about online self-harm discussion forums. SharpTalk was set up to facilitate shared learning between health professionals and young people who self-harm. We extracted themes and illustrative statements from the online discussion and asked participants to rate statements.

Results

Of 77 young people who participated in the forum, 47 completed the questionnaire. They said they learned more about mental health issues from online discussion forums than from information sites, found it easier to talk about self-harm to strangers than to family or friends, and preferred to talk online than face-to-face or on the telephone. They valued the anonymity the forums provided and reported feeling more able to disclose and less likely to be judged online than in ‘real life’.

Clinical implications

Mental health professionals should be aware of the value of anonymous online discussion forums for some young people who self-harm, so that they can talk about them and assess their use with their patients.

Postcards in Persia: A Twelve to Twenty-four Month Follow-up of a Randomized Controlled Trial for Hospital-Treated Deliberate Self-Poisoning

This study reports the outcomes, during follow-up, of a low-cost postcard intervention in a Randomized Control Trial of hospital-treated self-poisoning (n = 2300). The intervention was 9 postcards over 12 months (plus usual treatment) versus usual treatment. Three binary endpoints at 12-24 months (n = 2001) were: any suicidal ideation, suicide attempt, or self-cutting. There was a significant reduction in any suicidal ideation (RRR 0.20 CI 95% 0.13-0.27), (NNT 8, 6-13), and any suicide attempt (RRR 0.31, 0.06-0.50), (NNT 35, 19-195), in this non-western population. However, there was no effect on self-cutting (RRR -0.01, -1.05-0.51). Sustained, brief contact by mail may reduce some forms of suicidal behavior in self-poisoning patients during the post intervention phase.

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.

[Follow-up interventions after suicide attempt. What tools, what effects and how to assess them?]

After attempting suicide, 60 to 70% of patients are discharged from emergency departments and referred to outpatient treatment which entails psychosocial strategies, pharmacological strategies or a combination. The main objective of outpatient care consists in preventing recurrent suicidal behavior. Yet suicide attempters have been found to be very difficult to engage in treatment. Between 11% and 50% of attempters refuse outpatient treatment or drop out of outpatient therapy very quickly. In order to address this extremely serious issue, for the past 20 years monitoring or follow up interventions has been presented as a promising approach. Follow-up intervention is defined as a service that aims at both increased access to and engagement in care as well as to prevent suicide and related behaviors. This approach consists in "stay in contact" or "connectedness" protocols using phone calls or tele-assistance, sending letters, email or mobile phone messages and medical visits or nursing at home. From one study to another these tools have been used separately, associated to one another or reinforced by motivational interviewing or brief psychotherapy. To our knowledge, since 1993 16 controlled and randomized controlled studies assessed the effectiveness of diverse follow-up. Four studies assessing telephone follow up reported a significant decrease in suicide reattempt while one study evaluating a sending letters strategy reported positive results. Among five studies assessing engagement in healthcare, only two (one using phone follow up and the other sending letters reported significantly positive results. The refusal rate of monitoring strategies has not exceeded 11% attesting to the high applicability of these methods. Despite several positive results, we cannot draw firm conclusions on replicability of these results. This is largely due to methodological issues: lack of standardization of interventions, lack of consensus on definition of the main measured variables (recurrent suicidal behavior, engagement in healthcare) but also to the confounding effect of other care approaches frequently associated with follow up intervention services. Further studies and research should be conducted as follow-up intervention services are increasingly used in suicide prevention because of their good acceptability and usefulness.

Investigating the feasibility of an enhanced contact intervention in self-harm and suicidal behaviour: a protocol for a randomised controlled trial delivering a Social support and Wellbeing Intervention following Self Harm (SWISH)

INTRODUCTION

Self-harm is a strong predictor for suicide. Risks for repeat behaviour are heightened in the aftermath of an index episode. There is no consensus on the most effective type of intervention to reduce repetition. Treatment options for patients who do not require secondary mental health services include no support, discharge to general practitioner or referral to primary care mental health support services. The aim of this study is to assess whether it is feasible to deliver a brief intervention after an episode and whether this can reduce depressive symptoms and increase the sense of well-being for patients who self-harm.

METHODS

This is a non-blinded parallel group randomised clinical trial. 120 patients presenting with self-harm and/or suicidal ideation to mental health services over a 12-month period who are not referred to secondary services will be randomised to either intervention plus treatment as usual (TAU), or control (TAU only). Patients are assessed at baseline, 4 and 12 weeks with standardised measures to collect data on depression, well-being and service use. Primary outcome is depression scores and secondary outcomes are well-being scores and use of services. The findings will indicate whether a rapid response brief intervention is feasible and can reduce depression and increase well-being among patients who self-harm and do not require secondary services.

ETHICS AND DISSEMINATION

Ethical approval was granted by the UK National Health Service (NHS) Ethics Committee process (REC 6: 14/WA/0074). The findings of the trial will be disseminated through presentations to the participating Health Board and partners, peer-reviewed journals and national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN76914248; Pre-results.

Mechanisms of brief contact interventions in clinical populations: a systematic review

BACKGROUND

Brief Contact Interventions (BCIs) have been of increasing interest to suicide prevention clinicians, researchers and policy makers. However, there has been no systematic assessment into the mechanisms underpinning BCIs. The aim of the current paper is to provide a systematic review of the proposed mechanisms underpinning BCIs across trial studies.

METHOD

A systematic review was conducted of trials using BCIs (post-discharge telephone contacts; emergency or crisis cards; and postcard or letter contacts) for suicide or self-harm. Following PRISMA guidelines, we searched CENTRAL, MEDLINE, EMBASE, and the reference lists of all past reviews in the area. Secondary searches of reference lists were undertaken.

RESULTS

Sixteen papers provided a description of possible mechanisms which we grouped into three main areas: social support; suicide prevention literacy, and; learning alternative coping behaviours. After assessment of the studies and considering the plausibility of mechanisms, we suggest social support and improved suicide prevention literacy are the most likely mechanisms underpinning BCIs.

CONCLUSION

Researchers need to better articulate and measure the mechanisms they believe underpin BCIs in trial studies. Understanding more about the mechanisms of BCIs' will inform the development of future interventions for self-harm and suicide.

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.

MYPLAN - A Mobile Phone Application for Supporting People at Risk of Suicide

BACKGROUND

Safety plans have been suggested as an intervention for people at risk of suicide. Given the impulsive character of suicidal ideation, a safety plan in the format of a mobile phone application is likely to be more available and useful than traditional paper versions.

AIMS

The study describes MYPLAN, a mobile phone application designed to support people at risk of suicide by letting them create a safety plan.

METHOD

MYPLAN was developed in collaboration with clinical psychiatric staff at Danish suicide preventive clinics. The mobile application lets the user create an individualized safety plan by filling in templates with strategies, actions, and direct links to contact persons.

RESULTS

MYPLAN was developed in 2013 and is freely available in Denmark and Norway. It is designed for iPhone and android platforms. As of December 2015, the application has been downloaded almost 8,000 times. Users at risk of suicide as well as clinical staff have provided positive feedback on the mobile application.

CONCLUSION

Support via mobile phone applications might be particularly useful for younger age groups at risk of suicide as well as in areas or countries where support options are lacking. Yet, it is important to examine the effectiveness of this type of intervention.

Interventions for self-harm in children and adolescents

BACKGROUND

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

OBJECTIVES

To identify all randomised controlled trials of psychosocial interventions, pharmacological agents, or natural products for SH in children and adolescents, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., treatment as usual (TAU), placebo, or alternative pharmacological treatment) for children and adolescents who SH.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (30 January 2015).

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial or pharmacological treatments with treatment as usual, alternative treatments, or placebo or alternative pharmacological treatment in children and adolescents (up to 18 years of age) with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials, extracted data, and appraised study quality, with consensus. For binary outcomes, we calculated odds ratios (OR) and their 95% confidence intervals (CI). For continuous outcomes measured using the same scale we calculated the mean difference (MD) and 95% CI; for those measured using different scales we calculated the standard mean difference (SMD) and 95% CI. Meta-analysis was only possible for two interventions: dialectical behaviour therapy for adolescents and group-based psychotherapy. For these analyses, we pooled data using a random-effects model.

MAIN RESULTS

We included 11 trials, with a total of 1,126 participants. The majority of participants were female (mean = 80.6% in 10 trials reporting gender). All trials were of psychosocial interventions; there were none of pharmacological treatments. With the exception of dialectical behaviour therapy for adolescents (DBT-A) and group-based therapy, assessments of specific interventions were based on single trials. We downgraded the quality of evidence owing to risk of bias or imprecision for many outcomes.Therapeutic assessment appeared to increase adherence with subsequent treatment compared with TAU (i.e., standard assessment; n = 70; k = 1; OR = 5.12, 95% CI 1.70 to 15.39), but this had no apparent impact on repetition of SH at either 12 (n = 69; k = 1; OR 0.75, 95% CI 0.18 to 3.06; GRADE: low quality) or 24 months (n = 69; k = 1; OR = 0.69, 05% CI 0.23 to 2.14; GRADE: low quality evidence). These results are based on a single cluster randomised trial, which may overestimate the effectiveness of the intervention.For patients with multiple episodes of SH or emerging personality problems, mentalisation therapy was associated with fewer adolescents scoring above the cut-off for repetition of SH based on the Risk-Taking and Self-Harm Inventory 12 months post-intervention (n = 71; k = 1; OR = 0.26, 95% CI 0.09 to 0.78; GRADE: moderate quality). DBT-A was not associated with a reduction in the proportion of adolescents repeating SH when compared to either TAU or enhanced usual care (n = 104; k = 2; OR 0.72, 95% CI 0.12 to 4.40; GRADE: low quality). In the latter trial, however, the authors reported a significantly greater reduction over time in frequency of repeated SH in adolescents in the DBT condition, in whom there were also significantly greater reductions in depression, hopelessness, and suicidal ideation.We found no significant treatment effects for group-based therapy on repetition of SH for individuals with multiple episodes of SH at either the six (n = 430; k = 2; OR 1.72, 95% CI 0.56 to 5.24; GRADE: low quality) or 12 month (n = 490; k = 3; OR 0.80, 95% CI 0.22 to 2.97; GRADE: low quality) assessments, although considerable heterogeneity was associated with both (I(2) = 65% and 77% respectively). We also found no significant differences between the following treatments and TAU in terms of reduced repetition of SH: compliance enhancement (three month follow-up assessment: n = 63; k = 1; OR = 0.67, 95% CI 0.15 to 3.08; GRADE: very low quality), CBT-based psychotherapy (six month follow-up assessment: n = 39; k = 1; OR = 1.88, 95% CI 0.30 to 11.73; GRADE: very low quality), home-based family intervention (six month follow-up assessment: n = 149; k = 1; OR = 1.02, 95% CI 0.41 to 2.51; GRADE: low quality), and provision of an emergency card (12 month follow-up assessment: n = 105, k = 1; OR = 0.50, 95% CI 0.12 to 2.04; GRADE: very low quality). No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

There are relatively few trials of interventions for children and adolescents who have engaged in SH, and only single trials contributed to all but two comparisons in this review. The quality of evidence according to GRADE criteria was mostly very low. There is little support for the effectiveness of group-based psychotherapy for adolescents with multiple episodes of SH based on the results of three trials, the evidence from which was of very low quality according to GRADE criteria. Results for therapeutic assessment, mentalisation, and dialectical behaviour therapy indicated that these approaches warrant further evaluation. Despite the scale of the problem of SH in children and adolescents there is a paucity of evidence of effective interventions. Further large-scale trials, with a range of outcome measures including adverse events, and investigation of therapeutic mechanisms underpinning these interventions, are required. It is increasingly apparent that development of new interventions should be done in collaboration with patients to ensure that these are likely to meet their needs. Use of an agreed set of outcome measures would assist evaluation and both comparison and meta-analysis of trials.

Effect of Systematic Follow-Up by General Practitioners after Deliberate Self-Poisoning: A Randomised Controlled Trial

Objective

To assess whether systematic follow-up by general practitioners (GPs) of cases of deliberate self-poisoning (DSP) by their patients decreases psychiatric symptoms and suicidal behaviour compared with current practice.

Design

Randomised clinical trial with two parallel groups.

Setting

General practices in Oslo and the eastern part of Akershus County.

Participants

Patients aged 18–75 years admitted to hospital for DSP. We excluded patients diagnosed with psychoses, without a known GP, those not able to complete a questionnaire, and patients admitted to psychiatric in-patient care or other institutions where their GP could not follow them immediately after discharge.

Intervention

The GPs received a written guideline, contacted the patients and scheduled a consultation within one week after discharge, and then provided regular consultations for six months. We randomised the patients to either intervention (n = 78) or treatment as usual (n = 98).

Main Outcome Measures

Primary outcome measure was the Beck Scale for Suicide Ideation (SSI). Secondary outcomes were Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS), self-reported further self-harm and treatment for DSP in a general hospital or an emergency medical agency (EMA). We assessed patients on entry to the trial and at three and six months. We collected data from interviews, self-report questionnaires, and hospital and EMA medical records.

Results

There were no significant differences between the groups in SSI, BDI, or BHS mean scores or change from baseline to three or six months. During follow-up, self-reported DSP was 39.5% in the intervention group vs. 15.8% in controls (P = 0.009). Readmissions to general hospitals were similar (13% in both groups (P = 0.963), while DSP episodes treated at EMAs were 17% in the intervention group and 7% in the control group (P = 0.103).

Conclusion

Structured follow-up by GPs after an episode of DSP had no significant effect on suicide ideation, depression or hopelessness. There was no significant difference in repeated episodes of DSP in hospitals or EMAs. However, the total number of incidents of deliberate self-harm reported by the patients was significantly higher in the intervention group.

Trial registration

Trial registration ClinicalTrials.gov Identifier: NCT01342809

Quelqu’un pense à moi

L’objectif de cette communication est de rendre compte d’une démarche sociologique d’évaluation d’un programme de veille des conduites suicidaires : ALGOS . ALGOS est une étude nationale multicentrique (23 centres) de l’efficacité d’un algorithme de recontact après une tentative de suicide (carte ressource avec numéro d’urgence, appels téléphoniques et/ou cartes postales). Mille cinquante-cinq suicidants ont été inclus suite à leur passage aux urgences. Comment les différentes catégories d’acteurs (psychiatres, psychologues, généralistes, cellule de recontact, urgentistes, suicidants) ont-ils pu se sentir impliqués dans ce programme ? La méthodologie adoptée pour accéder aux comportements d’appropriation du dispositif est triple :

– des entretiens semi-directifs téléphoniques avec des médecins traitants (n = 10), psychiatres (n = 10) et psychologues (n = 3) suivant les patients en soins courants ;

– des entretiens semi-directifs en face à face avec les psychologues (n = 4) et attachées de recherche clinique (n = 2) de la cellule de recontact du centre d’investigation clinique et avec des patients (n = 29) ayant participé au programme ;

– des focus groupes (3) avec les professionnels des urgences (n = 27) ayant inclus les patients dans le programme.

L’implication de la cellule de recontact apparaît comme un atout majeur du dispositif qui transparaît dans le discours et le vécu subjectif des suicidants à travers la conviction : « Quelqu’un pense à moi ». La majorité des médecins, psychiatres et psychologues n’ont pas eu un sentiment d’implication dans le programme. Les professionnels des urgences ont eu des réactions très variées qui ne sont cependant pas corrélées avec le nombre d’inclusions. La majorité de ces professionnels a « joué le jeu ». Le programme semble être plus adapté à un profil spécifique de participants. Ces résultats sont mis en perspective par rapport à la discussion dans la littérature internationale .

Pharmacological interventions for self-harm in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Postdischarge Behavioral Health Treatment and 6-Month Reattempt Rate for Veterans Hospitalized for Suicide Attempt

BACKGROUND

The highest risk for suicide occurs immediately after psychiatric discharge. The U.S. Department of Veteran's Affairs' (VA) suicide prevention program emphasizes suicide surveillance and frequent contact after suicide attempt.

OBJECTIVES

To describe the 6-month reattempt rate and appointment characteristics for veterans after VA hospitalization for suicide attempt.

DESIGN

This retrospective observational study identified veterans hospitalized for suicide attempt (N = 504). Comparisons of patient characteristics and treatment delivery were conducted between veteran groups.

RESULTS

The sample (N = 504) was predominantly White (82%) and male (91%), with a median age of 50 years. The 6-month reattempt rate was 6%. Timing of first appointment was earlier in the reattempt group (n = 20) versus the no-reattempt group (n = 467). Appointment intensity, especially telephone appointments, was greater in the reattempt group.

CONCLUSION

The effect of postdischarge treatment on preventing suicide cannot be determined by evaluating only treatment timing and intensity. Future studies should measure the treatment quality and clinical severity.

Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis

BACKGROUND

A huge number of patients with self-harm and suicide attempt visit emergency departments (EDs). We systematically reviewed studies and examined the effect of interventions to prevent repeat suicidal behavior in patients admitted to EDs for a suicidal attempt.

METHOD

We searched the databases of MEDLINE, PsychoINFO, CINAHL, and EMBASE through August 2013. Eligible studies were randomized controlled trials assessing the effects on repeat suicidal behavior of interventions initiated in suicidal patients admitted to EDs. Interventions in each trial were classified into groups by consensus. Meta-analyses were performed to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of repetition of suicide attempt for interventions in each group.

RESULTS

Out of 5390 retrieved articles, 24 trials were included and classified into four groups (11 trials in the Active contact and follow-up, nine in the Psychotherapy, one in the Pharmacotherapy, and three in the Miscellaneous). Active contact and follow-up type interventions were effective in preventing a repeat suicide within 12 months (n=5319; pooled RR=0.83; 95% CI: 0.71 to 0.97). However, the effect at 24 months was not confirmed (n=925; pooled RR=0.98; 95% CI: 0.76-1.22). The effects of the other interventions on preventing a repetition of suicidal behavior remain unclear.

LIMITATION

Caution is needed regarding the heterogeneity of the effects.

CONCLUSION

Interventions of active contact and follow-up are recommended to reduce the risk of a repeat suicide attempt at 12 months in patients admitted to EDs with a suicide attempt. However, the long-term effect was not confirmed.

Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide

BACKGROUND

There is growing interest in brief contact interventions for self-harm and suicide attempt.

AIMS

To synthesise the evidence regarding the effectiveness of brief contact interventions for reducing self-harm, suicide attempt and suicide.

METHOD

A systematic review and random-effects meta-analyses were conducted of randomised controlled trials using brief contact interventions (telephone contacts; emergency or crisis cards; and postcard or letter contacts). Several sensitivity analyses were conducted to examine study quality and subgroup effects.

RESULTS

We found 14 eligible studies overall, of which 12 were amenable to meta-analyses. For any subsequent episode of self-harm or suicide attempt, there was a non-significant reduction in the overall pooled odds ratio (OR) of 0.87 (95% CI 0.74-1.04, P = 0119) for intervention compared with control. The number of repetitions per person was significantly reduced in intervention v. control (incidence rate ratio IRR = 066, 95% CI 0.54-0.80, P<0001). There was no significant reduction in the odds of suicide in intervention compared with control (OR = 0.58, 95% CI 0.24-1.38).

CONCLUSIONS

A non-significant positive effect on repeated self-harm, suicide attempt and suicide and a significant effect on the number of episodes of repeated self-harm or suicide attempts per person (based on only three studies) means that brief contact interventions cannot yet be recommended for widespread clinical implementation. We recommend further assessment of possible benefits in well-designed trials in clinical populations.

Assertive case management versus enhanced usual care for people with mental health problems who had attempted suicide and were admitted to hospital emergency departments in Japan (ACTION-J): a multicentre, randomised controlled trial

BACKGROUND

Non-fatal suicide attempt is the most important risk factor for later suicide. Emergency department visits for attempted suicide are increasingly recognised as opportunities for intervention. However, no strong evidence exists that any intervention is effective at preventing repeated suicide attempts. We aimed to investigate whether assertive case management can reduce repetition of suicide attempts in people with mental health problems who had attempted suicide and were admitted to emergency departments.

METHODS

In this multicentre, randomised controlled trial in 17 hospital emergency departments in Japan, we randomly assigned people aged 20 years and older with mental health problems who had attempted suicide to receive either assertive case management (based on psychiatric diagnoses, social risks, and needs of the patients) or enhanced usual care (control), using an internet-based randomisation system. Interventions were provided until the end of the follow-up period (ie, at least 18 months and up to 5 years). Outcome assessors were masked to group allocation, but patients and case managers who provided the interventions were not. The primary outcome was the incidence of first recurrent suicidal behaviour (attempted suicide or completed suicide); secondary outcomes included completed suicide and all-cause mortality. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444).

FINDINGS

Between July 1, 2006, and Dec 31, 2009, 914 eligible participants were randomly assigned, 460 to the assertive case management group and 456 to the enhanced usual care group. We noted no significant difference in incidence of first recurrent suicidal behaviour between the assertive case management group and the enhanced usual care group over the full study period (log-rank p=0·258). Because the proportional hazards assumption did not hold, we did ad-hoc analyses for cumulative incidence of the primary outcome at months 1, 3, 6, 12, and 18 after randomisation, adjusting for multiplicity with the Bonferroni method. Assertive case management significantly reduced the incidence of first recurrent suicidal behaviour up to the 6-month timepoint (6-month risk ratio 0·50, 95% CI 0·32-0·80; p=0·003), but not at the later timepoints. Prespecified subgroup analyses showed that the intervention had a greater effect in women (up to 18 months), and in participants younger than 40 years and those with a history of previous suicide attempts (up to 6 months). We did not identify any differences between the intervention and control groups for completed suicide (27 [6%] of 460 vs 30 [7%] of 454, log-rank p=0·660) or all-cause mortality (46 [10%] of 460 vs 42 [9%] of 454, log-rank p=0·698).

INTERPRETATION

Our results suggest that assertive case management is feasible in real-world clinical settings. Although it was not effective at reducing the incidence of repetition of suicide attempts in the long term, the results of our ad-hoc analyses suggested that it was effective for up to 6 months. This finding should be investigated in future research.

FUNDING

The Ministry of Health, Labour, and Welfare of Japan.

Prevalence of suicide attempters in emergency departments in Japan: a systematic review and meta-analysis

BACKGROUND

The number of hospital admissions related to suicide attempts is increasing worldwide. The Emergency Department (ED) is recognized in Japan as an opportunity to intervene with suicide attempters however, the prevalence of suicide attempters in the ED is unknown. Therefore, a meta-analysis was conducted to provide this information.

METHODS

We conducted searches of databases (PubMed, PsycINFO, CINAHL, ICHUSHI, CiNii) to identify studies about suicide attempters in the ED in Japan. A meta-analysis was used to calculate the pooled prevalence proportion of suicide attempters in the ED, and their prevalence proportion of psychiatric disorder and method of suicide in suicide attempters.

RESULTS

The search of Japanese studies identified 3338 records, of which 70 were included in the meta-analysis. A total of 25 studies reported the psychiatric diagnosis and 62 studies reported the method of suicide. The pooled prevalence proportion of suicide attempters was 4.7%. Mood disorders were the most frequent psychiatric disorders (ICD: 30%, DSM: 35%), and poisoning was the most frequent method of attempting suicide (52%).

LIMITATIONS

There might be a publication bias because only published studies were included. There also might be an information bias, such as reporting bias or misclassification, because most of studies included in the analysis used retrospective designs.

CONCLUSIONS

The results provide clear evidence of the prevalence of suicide attempters in the ED in Japan. The results indicate that suicide attempters in the ED have a higher proportion of mood disorders, and that the most common method of suicide is poisoning.

A contact-based intervention for people recently discharged from inpatient psychiatric care: a pilot study

People recently discharged from inpatient psychiatric care are at high risk of suicide and self-harm, with 6% of all suicides in England occurring in the 3 months after discharge. There is some evidence from a randomized trial carried out in the United States in the 1960s-70s that supportive letters sent by psychiatrists to high-risk patients in the period following hospital discharge resulted in a reduction in suicide. The aim of the current pilot study was to assess the feasibility of conducting a similar trial, but in a broader group of psychiatric discharges, in the context of present day UK clinical practice. The intervention was piloted on 3 psychiatric inpatient wards in southwest England. On 2 wards a series of 8 letters were sent to patients over the 12 months after discharge and 6 letters were sent from the third ward over a 6 month period. A total of 102 patients discharged from the wards received at least 1 letter, but only 45 (44.1%) received the full series of letters. The main reasons for drop-out were patient opt-out (n = 24) or readmission (n = 26). In the context of a policy of intensive follow-up post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this. Those interviewed felt that it was possible that the intervention might benefit people new to or with little follow-up from mental health services but that fewer letters should be mailed.

Can early follow-up after deliberate self-harm reduce repetition? A prospective study of 325 patients

BACKGROUND

Patients who deliberately harm themselves often repeat their self-destructive acts. The objective of this study was to assess whether a follow-up visit within 10 days to a psychiatric consultant could reduce the frequency of repeated deliberate self-harm (DSH).

METHODS

A cohort of 325 consecutive DSH patients attending two large emergency departments in Stockholm, Sweden, were included and followed for 6 months. Any visit to a psychiatric consultant within 10 days was registered as an early follow-up. Repeated DSH episode within 6 months among the 325 patients was detected via nationwide registers.

MAIN OUTCOME MEASURE

Repeated DSH within 6 months.

RESULTS

At 6 months follow-up 22 (24%) of 92 patients with an early follow-up had repeated their DSH acts compared to 58 (25%) of 233 patients without an early follow-up (OR 1.06 (95% CI: 0.60-1.85) p-value 0.85). After adjustment for possible confounders, multivariable analysis showed an OR of 1.22 (95% CI: 0.62-2.38, p-value 0.56).

LIMITATIONS

Early follow-up was registered as any visit to a psychiatric consultant and no information regarding actions taken at the visit were obtained.

CONCLUSION

After adjusting for other factors associated with repetition there was an association of patients who were offered and thereafter attended an early follow-up visit and a decreased risk of repeated DSH.

Can postdischarge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence

BACKGROUND

The time period following discharge from inpatient psychiatry and emergency department (ED) treatment is one of heightened risk for repeat suicide attempts for patients. Evidence reported in the literature shows that follow-up contacts might reduce suicide risk, although there has not been a comprehensive and critical review of the evidence to date.

AIMS

To evaluate evidence for the effectiveness of suicide prevention interventions that involve follow-up contacts with patients.

METHODS

Published empirical studies of follow-up interventions with suicidal behaviors (suicide, attempts, and ideation) as outcomes were searched. Study populations were inpatient psychiatric or ED patients being discharged to home. Contact modalities included phone, postal letter, postcards, in-person, and technology-based methods (e-mail and texting).

RESULTS

Eight original studies, two follow-up studies, and one secondary analysis study met inclusion criteria. Five studies showed a statistically significant reduction in suicidal behavior. Four studies showed mixed results with trends toward a preventative effect and two studies did not show a preventative effect.

CONCLUSIONS

Repeated follow-up contacts appear to reduce suicidal behavior. More research is needed, however, especially randomized controlled trials, to determine what specific factors might make follow-up contact modalities or methods more effective than others.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Supportive interchanges and face-work as 'protective talk' in an online self-harm support forum

Within a context of concern about inappropriate advice-giving online, we examined how young people who self-harm behave online, and how professionals might engage with them. We use Discourse Analysis to focus on participant interactions (posts)from a forum's crisis/support rooms, and highlight the prevalence of disclaimers, hedges, questions and tags in the young people's online interactions. We use the concept of face-work as a framework to help understand interactions in the forum SharpTalk. The findings demonstrate the use of a range of mitigation devices, and suggest that the young people orientate to a 'protective' line in their supportive interactions. These findings echo Goffman's (1967) 'supportive interchanges' in that the young people's online interactions may help to preserve face, in an emotionally complex setting, whose vulnerable members also need 'protective'and sensitive support. Taking this 'line' may enable members to create a more open and trusting context for support, and to remain in a forum which they find both helpful and challenging. In light of concerns about online support, the findings provide a new perspective on online peer-support for young people who self-harm.

Messages from Manchester: pilot randomised controlled trial following self-harm

Studies of therapeutic contact following self-harm have had mixed results. We carried out a pilot randomised controlled trial comparing an intervention (information leaflet listing sources of help, two telephone calls soon after presentation and a series of letters over 12 months) to usual treatment alone in 66 adults presenting with self-harm to two hospitals. We found that our methodology was feasible, recruitment was challenging and repeat self-harm was more common in those who received the intervention (12-month repetition rate 34.4% v. 12.5%).

Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning

BACKGROUND

Repetition of hospital-treated self-poisoning and admission to psychiatric hospital are both common in individuals who self-poison.

AIMS

To evaluate efficacy of postcard intervention after 5 years.

METHOD

A randomised controlled trial of individuals who have self-poisoned: postcard intervention (eight in 12 months) plus treatment as usual v. treatment as usual. Our primary outcomes were self-poisoning admissions and psychiatric admissions (proportions and event rates).

RESULTS

There was no difference between groups for any repeat-episode self-poisoning admission (intervention group: 24.9%, 95% CI 20.6-29.5; control group: 27.2%, 95% CI 22.8-31.8) but there was a significant reduction in event rates (incidence risk ratio (IRR) = 0.54, 95% CI 0.37-0.81), saving 306 bed days. There was no difference for any psychiatric admission (intervention group: 38.1%, 95% CI 33.1-43.2; control group: 35.5%, 95% CI 30.8-40.5) but there was a significant reduction in event rates (IRR = 0.66, 95% CI 0.47-0.91), saving 2565 bed days.

CONCLUSIONS

A postcard intervention halved self-poisoning events and reduced psychiatric admissions by a third after 5 years. Substantial savings occurred in general hospital and psychiatric hospital bed days.

Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: a qualitative study

BACKGROUND

Psychosocial assessment is a central aspect of managing self-harm in hospitals, designed to encompass needs and risk, and to lead to further care. However, little is known about service user experiences of assessment, or what aspects of assessment service users value. The aim of this study was to explore service user experiences of assessment, and examine the short-term and longer-term meanings of assessment for service users.

METHOD

Interpretative phenomenological analysis was applied to 13 interviews with service users following hospital attendance, and seven follow-up interviews conducted 3 months later.

RESULTS

Few participants had a clear understanding of assessment's purpose. Assessment had the potential to promote or challenge hope, dependent on whether it was experienced as accepting or critical. If follow-up care did not materialise, this reinforced hopelessness and promoted disengagement from services.

LIMITATIONS

The study sample was small and the participants heterogeneous in terms of self-harm history, method and intent, which may limit the transferability of the findings to other settings. Only self-report data on clinical diagnosis were collected.

CONCLUSIONS

This was the first study to utilise an in-depth qualitative approach to investigate service user experiences of assessment and follow-up. The findings suggest that re-conceptualising psychosocial assessment as primarily an opportunity to engage service users therapeutically may consequently affect how health services are perceived. In order to maintain benefits established during the hospital experience, follow-up needs to be timely and integrated with assessment.

Can receipt of a regular postcard reduce suicide-related behaviour in young help seekers? A randomized controlled trial

AIM

Suicide attempt, ideation and deliberate self-harm are common among adolescents. Limited evidence exists regarding interventions that can reduce risk; however, research indicates that maintaining contact with at-risk adults following discharge from services via letter or postcard can reduce risk. The aim of the study was to test a postcard intervention among people aged 15-24 who presented to mental health services but were not accepted, yet were at risk of suicide.

METHODS

A randomized controlled trial of 3 years in duration was used. The intervention consisted of 12 postcards sent once a month for 12 months following presentation to the service. Key outcomes of interest were reduced rates of suicide attempt, suicidal ideation and deliberate self-harm, assessed at 12 and 18 months.

RESULTS

Participants reported that they liked receiving the postcard and that they used the strategies recommended. However, no significant effect of the postcard intervention was found on suicide risk, although participants in both groups improved on measures of mental health over the course of the study.

CONCLUSIONS

There remains a need for further research into youth-friendly interventions for young people at risk of suicide.

Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation

OBJECTIVE

To examine the effectiveness and cost-effectiveness of group therapy for self harm in young people.

DESIGN

Two arm, single (assessor) blinded parallel randomised allocation trial of a group therapy intervention in addition to routine care, compared with routine care alone. Randomisation was by minimisation controlling for baseline frequency of self harm, presence of conduct disorder, depressive disorder, and severity of psychosocial stress.

PARTICIPANTS

Adolescents aged 12-17 years with at least two past episodes of self harm within the previous 12 months. Exclusion criteria were: not speaking English, low weight anorexia nervosa, acute psychosis, substantial learning difficulties (defined by need for specialist school), current containment in secure care. Setting Eight child and adolescent mental health services in the northwest UK.

INTERVENTIONS

Manual based developmental group therapy programme specifically designed for adolescents who harm themselves, with an acute phase over six weekly sessions followed by a booster phase of weekly groups as long as needed. Details of routine care were gathered from participating centres.

MAIN OUTCOME MEASURES

Primary outcome was frequency of subsequent repeated episodes of self harm. Secondary outcomes were severity of subsequent self harm, mood disorder, suicidal ideation, and global functioning. Total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses, were recorded.

RESULTS

183 adolescents were allocated to each arm (total n = 366). Loss to follow-up was low (<4%). On all outcomes the trial cohort as a whole showed significant improvement from baseline to follow-up. On the primary outcome of frequency of self harm, proportional odds ratio of group therapy versus routine care adjusting for relevant baseline variables was 0.99 (95% confidence interval 0.68 to 1.44, P = 0.95) at 6 months and 0.88 (0.59 to 1.33, P = 0.52) at 1 year. For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to 1.20, P = 0.29) at 6 months and 0.94 (0.63 to 1.40, P = 0.75) at 1 year. Total 1 year costs were higher in the group therapy arm (£21,781) than for routine care (£15,372) but the difference was not significant (95% CI -1416 to 10782, P = 0.132).

CONCLUSIONS

The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations. Trial registration ISRCTN 20496110.

"Well it's like someone at the other end cares about you." A qualitative study exploring the views of users and providers of care of contact-based interventions following self-harm

OBJECTIVE

We investigated the views of service users and staff regarding contact-based interventions (e.g., letters, telephone calls or crisis cards) following self-harm.

METHOD

Self-harm patients recently discharged from an emergency department were selected using purposive sampling (n=11). Clinical staff from relevant service areas and voluntary staff took part in a focus group and individual interviews (n=10). Interviews were transcribed and thematic analyses were conducted using methods of constant comparison to ensure that emergent themes remained grounded in the data.

RESULTS

Most service users and staff participants identified the period of time directly after discharge as the time of greatest need. A contact-based intervention was viewed by service users as a gesture of caring, which counteracted feelings of loneliness. Delivery by mental health specialists was preferred, initially by phone, but letters were considered helpful later. The intervention should be both genuine in delivery and linked to current services. Potential barriers included means of accessing the service and threats to privacy.

CONCLUSION

The findings suggest that an appropriate design for an intervention might be the provision of an information leaflet, telephone calls (soon after discharge), then letters (offering continuity of contact). Aspects of value and concern expressed by service users should be helpful to clinicians and service providers.