Psychosocial versus pharmacological treatments for deliberate self harm

Future-Oriented Group Training for suicidal individuals: A randomized controlled trial

INTRODUCTION

Suicide is a serious public health concern worldwide. Current psychological interventions targeting suicidal ideation and behavior are, however, limited and often lack convincing empirical support. Future-Oriented Group Training (FOGT) targets crucial aspects of the suicidal process, thus possibly offering a promising intervention for suicidal ideation. This study aimed at investigating the short-term and long-term effects of FOGT on suicidal thoughts and related variables.

METHODS

A randomized controlled trial was conducted, comparing the intervention group (FOGT + treatment as usual (TAU)) to a control group (TAU) at pre and posttreatment and at a 12-week follow-up. Suicidal ideation was the primary outcome, while depressive symptoms, hopelessness, defeat, entrapment, worrying, and the ability for future-oriented thinking were secondary outcomes.

RESULTS

When compared to the control group, the intervention group showed significant decreases in worrying at posttreatment and significant increases in future-oriented thinking at follow-up. Pre-post analyses within the intervention group showed significant small-to-medium effects for primary as well as most secondary outcomes. Changes in suicidal ideation, depression, hopelessness, and future-oriented thinking remained significant at follow-up.

CONCLUSION

This study provides promising empirical evidence for the use of FOGT for individuals with suicidal ideation.

Psychopathological and Interactive-Relational Characteristics in Non-Suicidal Self-Injury Adolescent Outpatients

Non-suicidal self-injury (NSSI) is described as behaviors that directly and intentionally inflict damage to body tissue without suicidal intent and for reasons not linked to cultural expectations or norms. Literature has confirmed several “specific risk factors” related to NSSI behaviors; emotional reactivity, internalizing problems, alexithymia traits, and maladaptive family functioning can predispose an individual to intrapersonal and interpersonal vulnerabilities related to difficulties in regulating one’s own cognitive-emotional experience. The present study aims to analyze and define the psychopathological and family interactive-relational characteristics of adolescents with NSSI through a case-control study. Thirty-one patients with NSSI and thirty-one patients without NSSI paired for sex, age, and psychiatric diagnosis (ICD-10) were recruited in Padua among two Child Neuropsychiatry Units before the COVID-19 pandemic. Results show a higher prevalence of internalizing problems, alexithymia trait related to “difficulty identifying feelings”, and lower quality of family functioning related to inclusion of partners, child involvement, and child self-regulation. These results carry significant implications for the clinical management and therapeutic care of non-suicidal self-injury patients and further confirm the need for an in-depth investigation of internalizing problems, alexithymia, and quality of family interactions.

Brief Interventions via Electronic Health Record Messaging for Population-Based Suicide Prevention: Mixed Methods Pilot Study

Background

New opportunities to create and evaluate population-based selective prevention programs for suicidal behavior are emerging in health care settings. Standard depression severity measures recorded in electronic medical records (EMRs) can be used to identify patients at risk for suicide and suicide attempt, and promising interventions for reducing the risk of suicide attempt in at-risk populations can be adapted for web-based delivery in health care.

Objective

This study aims to evaluate a pilot of a psychoeducational program, focused on developing emotion regulation techniques via a web-based dialectical behavior therapy (DBT) skills site, including four DBT skills, and supported by secure message coaching, including elements of caring messages.

Methods

Patients were eligible based on the EMR-documented responses to the Patient Health Questionnaire indicating suicidal thoughts. We measured feasibility via the proportion of invitees who opened program invitations, visited the web-based consent form page, and consented; acceptability via qualitative feedback from participants about the DBT program; and engagement via the proportion of invitees who began DBT skills as well as the number of website visits for DBT skills and the degree of site engagement.

Results

A total of 60 patients were invited to participate. Overall, 93% (56/60) of the patients opened the invitation and 43% (26/60) consented to participate. DBT skills website users visited the home page on an average of 5.3 times (SD 6.0). Procedures resulted in no complaints and some participant feedback emphasizing the usefulness of DBT skills.

Conclusions

This study supports the potential of using responses to patient health questionnaires in EMRs to identify a high-risk population and offer key elements of caring messages and DBT adapted for a low-intensity intervention. A randomized trial evaluating the effectiveness of this program is now underway (ClinicalTrials.gov: NCT02326883).

Psychosocial Interventions for Reducing Suicidal Behaviour and Alcohol Consumption in Patients With Alcohol Problems: A Systematic Review of Randomized Controlled Trials

OBJECTIVE

We aimed to provide a synthesis and evaluation of psychosocial interventions to prevent suicide and reduce self-harm, as well as alcohol intake, for patients with alcohol problems.

METHODS

The systematic review was carried out according to the PRISMA guidelines and considered articles published in English from all countries. Terms relating to suicidality and alcohol problems were used to search Medline, EMBASE and PsycINFO databases. Randomized controlled trials of psychosocial interventions targeted for outpatient settings were included.

RESULTS

Six studies with a total of 400 participants were included. Two investigated dialectic behavioural therapy (DBT), one internet-delivered DBT, one dynamic deconstructivist psychotherapy (DDP) and two integrated cognitive behavioural therapy (CBT). Face to face and online DBT was significantly associated with abstinence and reductions in consumption with only a trend for a reduction in suicide attempts in one study relative to treatment at usual (TAU). DDP yielded significant reductions in alcohol consumption and suicide attempts versus community care. CBT was significantly effective relative to TAU in reducing alcohol use and suicide attempts in one trial with adolescents but not in another trial in an adult population.

CONCLUSION

Integrated CBT has promise for adolescents, DBT may be helpful for alcohol patients with borderline personality disorder and iDBT may be useful for the wider community with heavy alcohol use. However, given the paucity of studies and the exploratory nature of these trials, there is currently no strong evidence for an effective psychosocial intervention to reduce alcohol consumption and suicidal behaviour in adults with problematic alcohol use.

Impact of Mental Health Treatment on Suicide Attempts

This paper analyzes the impact of mental health treatment on suicide attempts. While prior work demonstrates the effectiveness of mental health treatment at reducing suicide risk, few studies examine nationally representative populations or use broad measures of access to mental health services. A methodological problem can arise in studies of mental health treatment and suicidal behavior because a suicide attempt can result in the use of more mental health services. Using nationally representative survey data combined with national estimates of provider availability, this paper employs a methodological correction to address that potential problem of reverse causation. This paper uses measures of the density of health care providers in an area as statistical instruments for use of mental health treatment in an analysis of the impact of mental health treatment on suicide attempts. This study finds that mental health treatment significantly reduces suicide attempts.

Examining the Self-Harm and Suicide Contagion Effects of the Blue Whale Challenge on YouTube and Twitter: Qualitative Study

BACKGROUND

Research suggests that direct exposure to suicidal behaviors and acts of self-harm through social media may increase suicidality through imitation and modeling, particularly in more vulnerable populations. One example of a social media phenomenon that demonstrates how self-harming behavior could potentially be propagated is the blue whale challenge. In this challenge, adolescents and young adults are encouraged to engage in self-harm and eventually kill themselves.

OBJECTIVE

This paper aimed to investigate the way individuals portray the blue whale challenge on social media, with an emphasis on factors that could pose a risk to vulnerable populations.

METHODS

We first used a thematic analysis approach to code 60 publicly posted YouTube videos, 1112 comments on those videos, and 150 Twitter posts that explicitly referenced the blue whale challenge. We then deductively coded the YouTube videos based on the Suicide Prevention Resource Center (SPRC) safe messaging guidelines as a metric for the contagion risk associated with each video.

RESULTS

The thematic analysis revealed that social media users post about the blue whale challenge to raise awareness and discourage participation, express sorrow for the participants, criticize the participants, or describe a relevant experience. The deductive coding of the YouTube videos showed that most of the videos violated at least 50% of the SPRC safe and effective messaging guidelines.

CONCLUSIONS

These posts might have the problematic effect of normalizing the blue whale challenge through repeated exposure, modeling, and reinforcement of self-harming and suicidal behaviors, especially among vulnerable populations such as adolescents. More effort is needed to educate social media users and content generators on safe messaging guidelines and factors that encourage versus discourage contagion effects.

Feasibility of a randomised controlled trial of remotely delivered problem-solving cognitive behaviour therapy versus usual care for young people with depression and repeat self-harm: lessons learnt (e-DASH)

BACKGROUND

Self-harm and depression are strong risk factors for repeat self-harm and suicide. We aimed to investigate the feasibility of a randomised controlled trial (RCT) of remotely delivered problem-solving cognitive behaviour therapy (PSCBT) plus treatment as usual (TAU) versus TAU in young people with repeat self-harm and depression.

METHODS

Single-blind multi-centre RCT with an internal pilot, pre-set stop-go criteria and qualitative semi-structured interviews. Eligible participants (aged 16-30 years) were recruited from 9 adult or child and adolescent self-harm and crisis services; had ≥ 2 lifetime self-harm episodes, one in the preceding 96 h; and Beck Depression Inventory-II (BDI-II) score ≥ 17. Participants were randomised (1:1) to either TAU or TAU and 10-12 sessions of PSCBT delivered by mobile phone or video-calling.

RESULTS

Twenty-two participants were recruited (11 in each arm), 10 (46%) completed follow-up at 6 months, 9 (82%) started the PSCBT and 4 (36%) completed it. The study did not meet three of its four stop-go criteria, reflecting considerable barriers to recruitment and retention. Participants had severe depression symptoms: with mean BDI-II 38.9 in the PSCBT and 37.2 in TAU groups, respectively. Three (14%) unblindings occurred for immediate safety concerns. Barriers to recruitment and retention included lack of agency for participants, severity of depression, recency of crisis with burden for participants and clinicians who diagnosed depression according to pervasiveness.

CONCLUSIONS

RCTs of PSCBT for young people with depression and self-harm are not feasible using recruitment through mental health services that conduct assessments following self-harm presentations. Clinician assessment following self-harm presentation mainly identifies those with severe rather than mild-moderate depression.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02377011 ); Date of registration: March 3rd 2015. Retrospectively registered: within 21 days of recruitment of the first participant.

Cognitive Reappraisal Intervention for Suicide Prevention (CRISP) for Middle-Aged and Older Adults Hospitalized for Suicidality

Middle-aged and older adults constitute a high suicide-risk group. Among adults aged 50 years old and older, suicide rates increased and suicide deaths almost doubled during the period from 2000 to 2015. Suicide rates are elevated for patients hospitalized for suicidality (i.e., active suicidal ideation or suicide attempt) and the 3 months post-hospitalization is the time of the highest suicide risk. Psychosocial interventions for middle-aged and older adults hospitalized for suicidality are sparse. In this article, we present the main aspects, stages, techniques and a clinical case study of Cognitive Reappraisal Intervention for Suicide Prevention (CRISP), a psychosocial intervention targeting cognitive reappraisal to reduce suicide risk in middle-aged and older adults who have been recently hospitalized for suicidal ideation or a suicide attempt. CRISP is based on the theory that hospitalization for suicidality is preceded by an emotional crisis ("perfect storm"); this emotional crisis is related to personalized (patient- and situation-specific) triggers; and identifying these personalized triggers and the associated negative emotions and providing strategies for an adaptive response to these triggers and negative emotions will reduce suicidal ideation and improve suicide prevention. CRISP therapists identify these triggers of negative emotions and use cognitive reappraisal techniques to reduce these negative emotions. The cognitive reappraisal techniques have been selected from different psychosocial interventions and the affective neuroscience literature and have been simplified for use with middle-aged and older adults. CRISP may fill a treatment need for the post-discharge high-risk period for middle-aged and older adults hospitalized for suicidality.

Harm minimisation after repeated self-harm: development of a trust handbook

Repeated self-harm without suicidal intent occurs in approximately 2% of adults (Meltzer et al, 2002). Service users report that professionals can respond to self-harm with unhelpful attitudes and ineffective care. Although evidence for effective treatments is poor (Hawton et al, 1999), this therapeutic pessimism is not found in the self-help approaches promoted by voluntary organisations such as Mind: ‘If you feel the need to self-harm, focus on staying within safe limits' (Harrison & Sharman, 2005). User websites frequently offer advice on harm minimisation: ‘Support the person in beginning to take steps to keep herself safe and to reduce her self-injury – if she wishes to. Examples of very valuable steps might be: taking fewer risks (e.g. washing implements used to cut, avoiding drinking if she thinks she is likely to self-injure)’ (Bristol Crisis Service for Women, 1997).

Lithium and suicide in mood disorders: Updated meta-review of the scientific literature

OBJECTIVES

Suicide and suicidal behaviour are increased in mood disorders, particularly bipolar disorders. Observational studies and small randomized controlled trials (RCTs) support the idea that taking lithium is associated with a reduction in these rates. This paper aims to review the best evidence for the effect of lithium on rates of suicide and self harm.

METHODS

We searched PubMed, PsycINFO, and the Cochrane Library systematically for systematic reviews and meta-analyses of RCTs of lithium and suicide and self harm published between January 1980 and June 2017. In the case of multiple publications on the same topic, only the most recent or most comprehensive review was considered.

RESULTS

A large number of reviews were identified, but only 16 publications were systematic reviews. Of these, three systematic reviews of lithium and suicide rates and one of lithium and self harm confined only to RCTs were identified. Despite some methodological concerns and heterogeneity in terms of participants, diagnoses, comparators, durations, and phase of illness, the evidence to date is overwhelmingly in favour of lithium as an antisuicidal agent, even balanced against any potential disadvantages of its use in regular clinical practice.

CONCLUSIONS

The anti-suicidal effects of lithium have been consistently reported over the past 40 years. The most robust evidence comes from RCTs, but these results are also discussed in the context of the difficulties in conducting high quality studies in this area, and the supporting evidence that observational and non-randomized studies can also provide. Given this evidence, however, the use of lithium is still underrepresented in clinical practice and should be incorporated more assertively into current guidelines.

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study

IMPORTANCE

Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped.

OBJECTIVE

To determine whether an ED-initiated intervention reduces subsequent suicidal behavior.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013.

INTERVENTIONS

Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk.

MAIN OUTCOMES AND MEASURES

The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed.

RESULTS

A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99).

CONCLUSIONS AND RELEVANCE

Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Profile differences between overdose and non-overdose suicide attempts in a multi-ethnic Asian society

BACKGROUND

This study explores differences in characteristics of overdose (OD) and non-overdose (NOD) suicide attempts in Singapore.

METHODS

Four hundred eighty-five medical records of people who attempted suicide were extracted from a local general hospital patient database and classified into OD and NOD groups. Differences in socio-demographic factors, suicide characteristics and hospital admission types between both groups were examined.

RESULTS

Indians were more likely than the Chinese and Malays to employ OD method in their attempts. More suicide attempts in the OD group than NOD group were self-reported. The most likely place for suicide attempts for both groups was at home, though more NOD suicide attempts were in public areas as compared to the OD group. Analgesics were the most used substance in the OD group. Those who attempted suicide using OD had a higher number of psychiatric ward admissions than the NOD group. Risk and protective factors varied between both groups.

CONCLUSION

Differences in socio-demographics, suicide characteristics and admission characteristics between OD and NOD groups were observed. Recommendations for suicide prevention in the community are discussed. Further studies on the mediators and moderators of these trends and characteristics of suicide attempts are necessary to ensure maximal efficacy of prevention and management.

Do interventions reduce the risk of repeat self-harm or suicide in young people?

As in adults, self-harm in children and young people is common. It results in much distress to families and carers, and considerable morbidity among children and young people. Although much more common than completed suicide, it is strongly linked to repeated self-harm and suicide. The conclusions in this review are limited by the small number of studies included, no studies of pharmacological interventions at all and most of the included interventions being evaluated in a single study. One moderately sized study of mentalisation in adolescents with comorbid depression showed a significant effect on scores on a self-harm measure, indicating fewer self-reported episodes of self-harm. No other intervention showed a significant reduction in reported self-harm, although trials may have been too small to show statistical significance.

Dialectical Behaviour Therapy [DBT] with People with Intellectual Disabilities: A Systematic Review and Narrative Analysis

BACKGROUND

There is mixed evidence regarding the effectiveness of psychological therapies for people with intellectual and developmental disorders. Although systematic reviews have supported the use of dialectical behaviour therapy with people with borderline personality disorder, there are no comparable reviews regarding DBT with people with intellectual and development disabilities.

METHODS

Studies were identified using a systematic approach and were selected if they reported an intervention that included a DBT skills group and then assessed using the Evaluative Method for Determining Evidence Based Practice.

RESULTS

Seven studies reported adaptations and outcomes of DBT for people with intellectual and development disabilities, four of which delivered full DBT programmes with three describing DBT skills groups. All studies were appraised with regard to methodological quality and the adaptations and results examined.

CONCLUSIONS

The findings indicate that DBT and DBT skills groups can be adapted for people with intellectual and development disabilities, but further high-quality research is needed to make conclusions about efficacy and effectiveness.

Suicidal Individuals and Mental Health Treatment: A Novel Approach to Engagement

To determine the feasibility and acceptability of a novel, manualized problem-solving and comprehensive contact intervention (PS-CCI) aimed at improving treatment engagement of suicidal individuals. The PS-CCI was administered to 44 individuals with mood disorders presenting to the ER with suicidal ideation and/or behavior. The PS-CCI has two components: (1) a problem-solving interview administered upon admission to the emergency room (ER), and (2) follow-up contact post-discharge from the ER. The average age of participants was 33.45 years (SD = ±12.30). The PS-CCI was completed by 75 % of patients. No subject (0 %) withdrew during the 3-month follow-up period; however, 27.2 % were unable to be reached for follow-up assessment. We have concluded that the intervention has a good feasibility because of high acceptability and adherence and further testing of its efficacy seems feasible.

Trajectories of Suicidal Ideation in People Seeking Web-Based Help for Suicidality: Secondary Analysis of a Dutch Randomized Controlled Trial

BACKGROUND

Suicidal ideation (SI) is a common mental health problem. Variability in intensity of SI over time has been linked to suicidal behavior, yet little is known about the temporal course of SI.

OBJECTIVE

The primary aim was to identify prototypical trajectories of SI in the general population and, secondarily, to examine whether receiving Web-based self-help for SI, psychiatric symptoms, or sociodemographics predicted membership in the identified SI trajectories.

METHODS

We enrolled 236 people, from the general Dutch population seeking Web-based help for SI, in a randomized controlled trial comparing a Web-based self-help for SI group with a control group. We assessed participants at inclusion and at 2, 4, and 6 weeks. The Beck Scale for Suicide Ideation was applied at all assessments and was included in latent growth mixture modeling analysis to empirically identify trajectories.

RESULTS

We identified 4 SI trajectories. The high stable trajectory represented 51.7% (122/236) of participants and was characterized by constant high level of SI. The high decreasing trajectory (50/236, 21.2%) consisted of people with a high baseline SI score followed by a gradual decrease to a very low score. The third trajectory, high increasing (12/236, 5.1%), also had high initial SI score, followed by an increase to the highest level of SI at 6 weeks. The fourth trajectory, low stable (52/236, 22.0%) had a constant low level of SI. Previous attempted suicide and having received Web-based self-help for SI predicted membership in the high decreasing trajectory.

CONCLUSIONS

Many adults experience high persisting levels of SI, though results encouragingly indicate that receiving Web-based self-help for SI increased membership in a decreasing trajectory of SI.

A Pilot Study on the Efficacy of Volunteer Mentorship for Young Adults With Self-Harm Behaviors Using a Quasi-Experimental Design

BACKGROUND

Studies have shown that postdischarge care for self-harm patients is effective in reducing repeated suicidal behaviors. Little is known about whether volunteer support can help reduce self-harm repetition and improve psychosocial well-being.

AIM

This study investigated the efficacy of volunteer support in preventing repetition of self-harm.

METHOD

This study used a quasi-experimental design by assigning self-harm patients admitted to the emergency departments to an intervention group with volunteer support and treatment as usual (TAU) for 9 months and to a control group of TAU. Outcome measures include repetition of self-harm, suicidal ideation, hopelessness, and level of depressive and anxiety symptoms.

RESULTS

A total of 74 cases were recruited (38 participants; 36 controls). There were no significant differences in age, gender, and clinical condition between the two groups at the baseline. The intervention group showed significant improvements in hopelessness and depressive symptoms. However, the number of cases of suicide ideation and of repetition of self-harm episodes was similar for both groups at the postintervention period.

CONCLUSION

Postdischarge care provided by volunteers showed significant improvement in hopelessness and depression. Volunteers have been commonly involved in suicide prevention services. Further research using rigorous methods is recommended for improving service quality in the long term.

Disparities in suicide mortality trends between United States of America and 25 European countries: retrospective analysis of WHO mortality database

The objective was to examine changes in temporal trends in suicide mortality in 26 Western countries by retrospective trend analysis of the WHO mortality database on causes of deaths. From 1990 to 2010, there was a median reduction in suicide mortality of 22.7%, ranging from a 46% reduction in Estonia to a 26.2% increase in Romania. Suicide mortality decreased by ≥ 20% in 15 countries, and the reduction tended to be greater in countries with higher mortality in 1990. In most of the central European countries mortality strongly declined. The median changes in the age groups were -25.3% (range -62.9% to 72.6%) in people aged 15-24 years, -36.9% (-60.5% to 32.4%) in 25-34 years, -3.6% (-57.1% to 92%) in 35-54 years, -12.2% (-37% to 65,7%) in 55-74 years and -16.1% (-54.5% to 166.7%) in ≥ 75 years. Suicide prevention programs in youths and in the elderly seem to be effective (at least in females for the elderly) and efforts should be pursued in this way. However, suicide mortality of the people aged 35-54 years has increased in half of the studied countries between 1990 and 2010. Public policies should further orientate their efforts toward this population.

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.

Self-Harm Intervention: Family Therapy (SHIFT), a study protocol for a randomised controlled trial of family therapy versus treatment as usual for young people seen after a second or subsequent episode of self-harm

BACKGROUND

Self-harm is common in the community with a lifetime prevalence of 13 %. It is associated with an elevated risk of overall mortality and suicide. People who harm themselves are high users of public services. Estimates of the 1-year risk of repetition vary between 5 and 15 % per year. Currently, limited evidence exists on the effectiveness of clinical interventions for young people who engage in self-harm. Recent reviews have failed to demonstrate any effect on reducing repetition of self-harm among adolescents receiving a range of treatment approaches. Family factors are particularly important risk factors associated with fatal and non-fatal self-harm among children and adolescents. Family therapy focuses on the relationships, roles and communication patterns between family members, but there have been relatively few studies of specifically family-focused interventions with this population. The Self-Harm Intervention: Family Therapy (SHIFT) Trial was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (grant no. 07/33/01) following a commissioned call for this research.

METHODS/DESIGN

SHIFT is a pragmatic, phase III, multicentre, individually randomised, controlled trial comparing Family Therapy (FT) with treatment as usual (TAU) for adolescents aged 11 to 17 who have engaged in at least two episodes of self-harm. Both therapeutic interventions were delivered within the National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) in England. Participants and therapists were, of necessity, aware of treatment allocation, but the researchers were blind to the allocations to allow unbiased collection of follow-up data. Primary outcome data (repetition of self-harm leading to hospital attendance 18 months post-randomisation) were collected from the Health and Social Care Information Centre (HSCIC), augmented by directed searches of medical records at Acute Trusts. Secondary outcome data (including suicidal intent, depression, hopelessness and health economics) were collected at 12 and 18 months post-randomisation via researcher-participant interviews and by post at 3 and 6 months.

DISCUSSION

SHIFT will provide a well-powered evaluation of the clinical and cost effectiveness of Family Therapy for young people who have self-harmed on more than one occasion. The study will be reported in 2016, and the results will inform clinical practice thereafter.

TRIAL REGISTRATION

ISRCTN59793150 . 26 January 2009.

Structured follow-up by general practitioners after deliberate self-poisoning: a randomised controlled trial

BACKGROUND

General Practitioners (GPs) play an important role in the follow-up of patients after deliberate self-poisoning (DSP). The aim was to examine whether structured follow-up by GPs increased the content of, adherence to, and satisfaction with treatment after discharge from emergency departments.

METHODS

This was a multicentre, randomised trial with blinded assignment. Five emergency departments and general practices in the catchment area participated. 202 patients discharged from emergency departments after DSP were assigned. The intervention was structured follow-up by the GP over a 6-month period with a minimum of five consultations, accompanied by written guidelines for the GPs with suggestions for motivating patients to follow treatment, assessing personal problems and suicidal ideation, and availability in the case of suicidal crisis. Outcome measures were data retrieved from the Register for the control and payment of reimbursements to health service providers (KUHR) and by questionnaires mailed to patients and GPs. After 3 and 6 months, the frequency and content of GP contact, and adherence to GP consultations and treatment in general were registered. Satisfaction with general treatment received and with the GP was measured by the EUROPEP scale.

RESULTS

Patients in the intervention group received significantly more consultations than the control group (mean 6.7 vs. 4.5 (p = 0.004)). The intervention group was significantly more satisfied with the time their GP took to listen to their personal problems (93.1% vs. 59.4% (p = 0.002)) and with the fact that the GP included them in medical decisions (87.5% vs. 54. 8% (p = 0.009)). The intervention group was significantly more satisfied with the treatment in general than the control group (79% vs. 51% (p = 0.026)).

CONCLUSIONS

Guidelines and structured, enhanced follow-up by the GP after the discharge of the DSP patient increased the number of consultations and satisfaction with aftercare in general practice. Consistently with previous research, there is still a need for interventional studies.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01342809. Registered 18 April 2011.

Psychopharmacological Agents and Suicide Risk Reduction: Ketamine and Other Approaches

Suicide is a major global public health problem and the leading cause of injury mortality in the USA. Suicide is a complex phenomenon involving several systems and neurobiological pathways, with interacting genetic and environmental mechanisms. The literature on the neurobiology and pharmacotherapy of suicide has been limited. To date, no medications have proven efficacious for treating acute suicidal crises. There is an emerging literature supporting a rapid anti-suicidal effect of ketamine, a non-competitive N-methyl-D-aspartate (NMDA) glutamate receptor antagonist, among depressed patients with suicidal ideation. Potential ketamine's anti-suicidal effect mechanisms are linked to interruption of the kynurenine pathway and modulating pro-inflammatory cytokines exacerbation. However, available data are not sufficient for its routine integration in clinical practice, and larger and replicated randomized control studies are needed.

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.

Reducing suicidal thoughts in the Australian general population through web-based self-help: study protocol for a randomized controlled trial

Background

Suicidal thoughts are common in the general population, causing significant disability. However, a substantial number of people struggling with suicidality do not access appropriate services. Online self-help may help overcome barriers to help-seeking. This study aims to examine the effectiveness of an online self-help program targeted at reducing suicidal thoughts compared with an attention-matched control condition in the Australian adult population. This trial is based on a Dutch self-help program, which was found to be effective in reducing suicidal thoughts.

Methods/Design

A total of 570 community-dwelling adults (18 to 65 years old) with suicidal thoughts will be recruited via various media and randomly assigned to the 6-week online program aimed at reducing suicidal thoughts or a 6-week attention-matched control program. Primary outcome measure is the severity of suicidal thoughts. Secondary outcome measures include suicide plans, capacity to cope with suicidal thoughts, reasons for living, symptoms of depression, hopelessness, anxiety/worry, rumination, panic, perceived burdensomeness and thwarted belongingness, acquired capability, alcohol consumption, insomnia, and various cost-effectiveness measures.

Discussion

Although the original Dutch trial found web-based self-help to be effective in reducing suicidal thoughts, randomized controlled trials (RCT) of online programs for suicidal thoughts are rare. The present study extends previous research by running the first English language RCT of this sort. As a result of the original study, the current RCT includes refinements to the design, including greater levels of participant anonymity and longer follow-up periods. Limitations of this trial include the potential for high drop-out and the inability to ascertain whether any suicides occur during the study.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) Registration number: ACTRN12613000410752 (15 April 2013). Universal Trial Number (UTN): U1111-1141-6595 (15 April 2013).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0589-1) contains supplementary material, which is available to authorized users.

Self-reported Usual Care for Self-directed Violence During the 6 Months Before Emergency Department Admission

BACKGROUND

The literature describing the health services individuals receive before and following self-directed violence (SDV) is limited.

OBJECTIVES

This study examines services received for the 6 months preceding admission to an urban county medical center emergency department (ED) for SDV. We predicted that individuals with at least 1 prior act of SDV in the past 6 months would have received more services than those for whom the index admission was their only recent act.

METHODS

Participants were recruited from ED admissions during shifts selected to maximize representativeness. Participants (n=202) were interviewed using the Suicide Attempt Self-Injury Interview, Suicide Attempt Self-Injury Count, Treatment History Interview, Mini International Neuropsychiatric Interview, Brief Symptom Index, and SF-12.

RESULTS

The majority of index acts of SDV (79%) were suicide attempts. The participants were characterized by low socioeconomic status, substantial symptomatology, low physical and mental health functioning, and multiple psychiatric diagnoses. In the preceding 6 months, 34% were admitted to a hospital and 56% received crisis services (including 44% in the ED). Although three quarters (76%) had seen an outpatient medical provider and most (70%) received psychotropic medications, less than half of the sample received psychiatric services (40%) or outpatient psychosocial treatment (48%). As predicted, utilization for most types of usual care was higher for those engaging in SDV in the 6 months preceding the index admission.

CONCLUSION

Individuals admitted to this ED for SDV received inadequate outpatient psychosocial and psychiatric services despite severe illness and disability.

Interventions for primary prevention of suicide in university and other post-secondary educational settings

BACKGROUND

Suicide is a leading cause of death among post-secondary students worldwide. Suicidal thoughts and planning are common among post-secondary students. Previous reviews have examined the effectiveness of interventions for symptomatic individuals; however, many students at high risk of suicide are undiagnosed and untreated.

OBJECTIVES

We evaluated the effect on suicide and suicide-related outcomes of primary suicide prevention interventions that targeted students within the post-secondary setting.

SEARCH METHODS

We searched the following sources up to June 2011: Specialised Registers of two Cochrane Groups, Cochrane Central Register of Controlled Trials, and nine other databases, trial registers, conference proceedings, and websites of national and international organizations. We screened reference lists and contacted authors of included studies to identify additional studies. We updated the search in November 2013; we will include these results in the review's next update.

SELECTION CRITERIA

We included studies that tested an intervention for the primary prevention of suicide using a randomized controlled trial (RCT), controlled before-and-after (CBA), controlled interrupted time series (CITS), or interrupted time series (ITS) study design. Interventions targeted students within the post-secondary setting (i.e. college, university, academy, vocational, or any other post-secondary educational institution) without known mental illness, previous suicide attempt or self-harm, or suicidal ideation. Outcomes included suicides, suicide attempts, suicidal ideation, changes in suicide-related knowledge, attitudes and behavior, and availability of means of suicide.

DATA COLLECTION AND ANALYSIS

We used standardized electronic forms for data extraction, risk of bias and quality of evidence determination, and analysis. We estimated standardised mean differences (SMD) with 95% confidence intervals (CIs). We analysed studies by intervention type and study design. We summarized RCT effect sizes using random-effects models meta-analyses; and analysed statistical heterogeneity using the Chi(2) test and I(2) statistic. We described narratively the results from studies that used other study designs.

MAIN RESULTS

Eight studies met inclusion criteria. They were heterogeneous in terms of participants, study designs, and interventions. Five of eight studies had high risk of bias. In 3 RCTs (312 participants), classroom-based didactic and experiential programs increased short-term knowledge of suicide (SMD = 1.51, 95% CI 0.57 to 2.45; moderate quality evidence) and knowledge of suicide prevention (SMD = 0.72, 95% CI 0.36 to 1.07; moderate quality evidence). The effect on suicide prevention self-efficacy in one RCT (152 participants) was uncertain (SMD = 0.20, 95% CI -0.13 to 0.54; low quality evidence). One CBA analysed the effects of an institutional policy that restricted student access to laboratory cyanide and mandated professional assessment for suicidal students. The incidence of student suicide decreased significantly at one university with the policy relative to 11 control universities, 2.00 vs. 8.68 per 100,000 (Z = 5.90; P < 0.05). Four CBAs explored effects of training 'gatekeepers' to recognize and respond to warning signs of emotional crises and suicide risk in students they encountered. The magnitude of effect sizes varied between studies. Gatekeeper training enhanced short-term suicide knowledge in students, peer advisors residing in student accommodation, and faculty and staff, and suicide prevention self-efficacy among peer advisors. There was no evidence of an effect on participants' suicide-related attitudes or behaviors. One CBA found no evidence of effects of gatekeeper training of peer advisors on suicide-related knowledge, self-efficacy, or gatekeeper behaviors measured four to six months after intervention.

AUTHORS' CONCLUSIONS

We found insufficient evidence to support widespread implementation of any programs or policies for primary suicide prevention in post-secondary educational settings. As all evaluated interventions combined primary and secondary prevention components, we were unable to determine the independent effects of primary preventive interventions. Classroom instruction and gatekeeper training increased short-term suicide-related knowledge. We found no studies that tested the effects of classroom instruction on suicidal behavior or long-term outcomes. Limited evidence suggested minimal longer-term effects of gatekeeper training on suicide-related knowledge, while no evidence was found evaluating its effect on suicidal behavior. A policy-based suicide intervention reduced student suicide, but findings have not been replicated. Our findings are limited by the overall low quality of the evidence and the lack of studies from middle- and low-income countries. Rigorously designed studies should test the effects of preventive interventions on important health outcomes, including suicidal ideation and behavior, in varying post-secondary settings.

Effectiveness of lithium in subjects with treatment-resistant depression and suicide risk: results and lessons of an underpowered randomised clinical trial

Background

As lithium treatment might be effective in reducing the risk of deliberate self-harm (DSH) in adult patients with unipolar affective disorders, we designed a pragmatic randomised trial to assess its efficacy in more than 200 patients with treatment-resistant depression. However, we randomised 56 patients only. The aim of this report is therefore twofold: first, to disseminate the results of this underpowered study which may be incorporated into future meta-analytical reviews; second, to analyse some critical aspects of the study which might explain failure to reach the target sample size.

Methods

We carried out a randomised, parallel group, assessor-blinded superiority clinical trial. Adults with a diagnosis of major depression, an episode of DSH in the previous 12 months and inadequate response to at least two antidepressants given sequentially at an adequate dose for an adequate time for the current depressive episode were allocated to add lithium to usual care (intervention arm) versus usual care alone (control arm). Suicide completion and acts of DSH during the 12 months of follow-up constituted the composite primary outcome.

Results

Of 58 patients screened for inclusion, 29 were allocated to lithium plus usual care and 27 were assigned to usual care without lithium. Six patients in the lithium plus usual care group and seven in the usual care group committed acts of DSH during the follow-up phase. The survival probability did not differ between the two treatment arms (Chi² = 0.17, p =0.676). With regard to changes in the severity of depressive symptomatology from baseline to endpoint, no significant differences were detected.

Conclusions

The present study failed to achieve the minimum sample size needed to detect a clinically meaningful difference between the two treatment arms. Consequently, the finding that lithium, in addition to usual care, did not exert a positive effect in terms of reduction of DSH after 12 months of follow-up is likely due to the lack of sufficient statistical power to detect a difference, if a difference existed. The dissemination of the results of this underpowered study will inform future meta-analytical reviews on lithium and suicide-related outcomes.

Trial registration

ClinicalTrials.gov identifier: NCT00927550

Effectiveness of group dialectical behavior therapy (based on core distress tolerance and emotion regulation components) one expulsive anger and impulsive behaviors

INTRODUCTION

The purpose of this study is to measure Effectiveness of group dialectical behavior therapy (based on core distress tolerance and emotion regulation components) on Expulsive Anger and Impulsive Behaviors.

MATERIALS & METHODS

Research method is a semi experimental socio-statistic approach consisting of experimental group (dialectical behavior therapy) and control group. Participants were patients referred to Amir Kabir Hospital in Arak who suffered from Expulsive Anger and Impulsive Behaviors. Based on stratified random sampling, 16 patients (women) were placed in each group. Research tools included the structured diagnosis interview according to DSM-IV-TR (2000), Barrat impulsivity scale(1994) Distress Tolerance Scale (2005) Difficulties of Emotion Regulation Scale (2004) and dialectical behavior therapy were done for two months,8 group-sessions).

FINDINGS

Dialectical behavior therapy was effective on Expulsive Anger and Impulsive Behaviors.

DISCUSSION & CONCLUSION

Distress tolerance and emotion regulation components were effective on Expulsive Anger and Impulsive Behaviors.

Does cognitive behavioural therapy have a role in improving problem solving and coping in adolescents with suicidal ideation?

Problem-solving and coping skills deficits have been shown in adolescents who experience suicide-related behaviours, including suicidal ideation. Little evidence exists about effective interventions for this population. We undertook a pilot study of an Internet-based CBT programme that included problem-solving skills training to investigate its impact on skills deficits. The study employed a pre-test/post-test design. Outcomes of interest were negative problem orientation, emotion- and task-focused coping, and adolescents’ perception of helpfulness of the intervention. Participants, recruited via the school wellbeing team, were assessed at baseline, at weekly intervention sessions and immediately post-intervention. Twenty-one adolescents completed the intervention. Over the course of the intervention, negative problem-solving orientation improved and students relied less on emotion-focused coping strategies. Because there was no control group, we cannot be certain that the changes seen between baseline and post-intervention can be attributed to the intervention. Adolescents rated the problem-solving and cognitive restructuring modules as particularly helpful. Interventions that include enhancement of problem-solving skills, as well as cognitive restructuring to address adolescents’ appraisal of problems and their ability to solve them appear promising for adolescents with suicidal ideation. Further investigation is warranted.

MIDSHIPS: multicentre intervention designed for self-harm using interpersonal problem-solving: protocol for a randomised controlled feasibility study

BACKGROUND

Around 150,000 people each year attend hospitals in England due to self-harm, many of them more than once. Over 5,000 people die by suicide each year in the UK, a quarter of them having attended hospital in the previous year because of self-harm. Self-harm is a major identifiable risk factor for suicide. People receive variable care at hospital; many are not assessed for their psychological needs and little psychological therapy is offered. Despite its frequent occurrence, we have no clear research evidence about how to reduce the repetition of self-harm. Some people who have self-harmed show less active ways of solving problems, and brief problem-solving therapies are considered the most promising psychological treatments.

METHODS/DESIGN

This is a pragmatic, individually randomised, controlled, feasibility study comparing interpersonal problem-solving therapy plus treatment-as-usual with treatment-as-usual alone, for adults attending a general hospital following self-harm. A total of 60 participants will be randomised equally between the treatment arms, which will be balanced with respect to the type of most recent self-harm event, number of previous self-harm events, gender and age. Feasibility objectives are as follows: a) To establish and field test procedures for implementing the problem-solving intervention; b) To determine the feasibility and best method of participant recruitment and follow up; c) To assess therapeutic delivery; d) To assess the feasibility of obtaining the definitive trial's primary and secondary outcomes; e) To assess the perceived burden and acceptability of obtaining the trial's self-reported outcome data; f) To inform the sample size calculation for the definitive trial.

DISCUSSION

The results of this feasibility study will be used to determine the appropriateness of proceeding to a definitive trial and will allow us to design an achievable trial of interpersonal problem-solving therapy for adults who self-harm.

TRIAL REGISTRATION

Current Controlled Trials (ISRCTN54036115).

Psychosocial interventions for suicidal ideation, plans, and attempts: a database of randomised controlled trials

BACKGROUND

Research in suicide prevention using psychosocial interventions is rapidly advancing. However, randomised controlled trials are published across a range of medical, psychological and sociology journals, and it can be difficult to locate a full set of research studies. In this paper, we present a database of randomised controlled outcome studies on psychosocial interventions targeting suicidal behaviour. The database is updated annually and can be accessed by contacting the corresponding author.

DESCRIPTION

A comprehensive literature search of the major bibliographical databases (PsycINFO; PubMed; Cochrane Central Register of Controlled Trials) was conducted for articles published between 1800 to July 30 2013, and examined reference lists of previous relevant reviews and included papers to locate additional references. Studies were included if they featured a randomised controlled design in which the effects of a psychosocial intervention were compared to a control condition (no intervention, attention placebo, wait-list, treatment-as-usual [TAU]), another psychosocial intervention or a pharmacological intervention. In total, 12,250 abstracts were identified. Of these, 131 studies met eligibility criteria and were included. Each paper was then coded into categories of participant characteristics (age, gender, formal diagnosis, primary reason for recruitment); details of the intervention (recruitment setting, content, intervention setting, administering individual, delivery type, delivery format, delivery frequency, delivery length); and study characteristics (control and experimental conditions, primary outcome/s, secondary outcome/s, follow-up period). One paper has been published from the database using studies collected and coded prior to 2012.

CONCLUSION

The database and listing of 131 studies is available for use by suicide prevention researchers. It provides a strong starting point for systematic reviews and meta-analyses of treatments and interventions. It will be updated yearly by researchers funded through the Australian National Health and Medical Research Council Centre for Research Excellence for Suicide Prevention (CRESP), located at the Black Dog Institute, Australia. This database adds to the evidence base of best-practice psychosocial interventions for suicidal behaviour and prevention.

Effectiveness of online self-help for suicidal thoughts: results of a randomised controlled trial

Background

Many people with suicidal thoughts do not receive treatment. The Internet can be used to reach more people in need of support.

Objective

To test the effectiveness of unguided online self-help to reduce suicidal thoughts.

Method

236 adults with mild to moderate suicidal thoughts were randomised to the intervention (n = 116) or a waitlist control group (n = 120). Assessments took place at baseline, and 2, 4 and 6 weeks later. Primary outcome was suicidal thoughts. Secondary outcomes were depressive symptoms, anxiety, hopelessness, worry, and health status.

Results

The intervention group showed a small significant effect in reducing suicidal thoughts (d = 0.28). Effects were more pronounced for those with a history of repeated suicide attempts. There was also a significant reduction in worry (d = 0.33). All other secondary outcomes showed small but non-significant improvements.

Conclusions

Although effect sizes were small, the reach of the internet could enable this intervention to help many people reduce their suicidal thoughts.

Trial Registration

Netherlands Trial Register NTR1689

Effectiveness of lithium in subjects with treatment-resistant depression and suicide risk: a protocol for a randomised, independent, pragmatic, multicentre, parallel-group, superiority clinical trial

BACKGROUND

Data on therapeutic interventions following deliberate self harm (DSH) in patients with treatment-resistant depression (TRD) are very scant and there is no unanimous consensus on the best pharmacological option for these patients. There is some evidence that lithium treatment might be effective in reducing the risk of completed suicide in adult patients with unipolar affective disorders, however no clear cut results have been found so far. The primary aim of the present study is to assess whether adding lithium to standard therapy is an effective treatment strategy to reduce the risk of suicidal behaviour in long term treatment of people with TRD and previous history of DSH.

METHODS/DESIGN

We will carry out a randomised, parallel group, assessor-blinded superiority clinical trial. Adults with a diagnosis of major depression, an episode of DSH in the previous 12 months and inadequate response to at least two antidepressants given sequentially at an adequate dose for an adequate time for the current depressive episode will be allocated to add lithium to current therapy (intervention arm) or not (control arm). Following randomisation, treatment is to be taken daily for 1 year unless some clear reason to stop develops. Suicide completion and acts of DSH during the 12 months of follow-up will constitute the composite primary outcome. To preserve outcome assessor blindness, an independent adjudicating committee, blind to treatment allocation, will anonymously review all outcome events.

DISCUSSION

The results of this study should indicate whether lithium treatment is associated with lower risk of completed suicide and DSH in adult patients with treatment resistant unipolar depression, who recently attempted suicide.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00927550.

Effectiveness of a nationwide aftercare program for suicide attempters

BACKGROUND

The effectiveness of large-scale interventions to prevent suicide among persons who previously attempted suicide remains to be determined. The National Suicide Surveillance System (NSSS), launched in Taiwan in 2006, is a structured nationwide intervention program for people who survived their suicide attempts. This naturalistic study examined its effectiveness using data from the first 3 years of its operation. Method Effectiveness of the NSSS aftercare services was examined using a logistic/proportional odds mixture model, with eventual suicide as the outcome of interest. As well, we examined time until death for those who died and factors associated with eventual suicide.

RESULTS

Receipt of aftercare services was associated with reduced risk for subsequent suicide; for service recipients who eventually killed themselves, there was a prolonged duration between the index and fatal attempts. Elderly attempters were particularly prone to a shorter duration between the index and fatal attempts. Male gender, the lethality potential of the index attempt, and a history of having had a mental disorder also were associated with higher risk.

CONCLUSIONS

The structured aftercare program of the NSSS appears to decrease suicides and to delay time to death for those who remained susceptible to suicide.

Teaching evidence-based approaches to suicide risk assessment and prevention that enhance psychiatric training

This report describes one in a series of National Institute of Health (NIH) supported conferences aimed at enhancing the ability of leaders of psychiatry residency training to teach research literacy and produce both clinician-scholars and physician-scientists in their home programs. Most psychiatry training directors would not consider themselves research scholars or even well-schooled in evidence based practice. Yet they are the front line educators to prepare tomorrow's psychiatrists to keep up with, critically evaluate, and in some cases actually participate in the discovery of new and emerging psychiatric knowledge. This annual conference is meant to help psychiatry training directors become more enthusiastic, knowledgeable and pedagogically prepared to create research-friendly environments at their home institutions, so that more trainees will, in turn, become research literate, practice evidence-based psychiatry, and enter research fellowships and careers. The overall design of each year's meeting is a series of plenary sessions introducing participants to new information pertaining to the core theme of that year's meeting, integrated with highly interactive small group teaching sessions designed to consolidate knowledge and provide pragmatic teaching tools appropriate for residents at various levels of training. The theme of each meeting, selected to be a compelling and contemporary clinical problem, serves as a vehicle to capture training directors' attention while teaching relevant brain science, research literacy and effective pedagogy. This report describes the content and assessment of the 2011 annual pre-meeting, "Evidence-based Approaches to Suicide Risk Assessment and Prevention: Insights from the Neurosciences and Behavioral Sciences for use in Psychiatry Residency Training."

The association between social relationships and self-harm: a case-control study in Taiwan

BACKGROUND

Although suicide has been postulated as a result of social breakdown, relatively little attention has been paid to the association between social relationships and non-fatal self-harm. We sought to investigate the extent to which social factors correlate with self-harm in this case-control study.

METHODS

The primary outcome was self-harm with hospital presentation. Cases of self-harm from the Emergency Department in a general hospital in Northern Taiwan were recruited, and individually age-and-gender-matched control participants were recruited from non-psychiatric outpatient clinics at the same hospital. The Close Persons Questionnaire was administered and its social support and social network subscales were used to measure social relationships in the 12 months prior to the interview. Other covariates, comprising sociodemographic factors, major life events, physical and mental health, were adjusted in conditional logistic regression models.

RESULTS

A total of 124 case-control pairs were recruited. The mean (standard deviation) age of the case group was 34.7 (12.8) years and 80.6% were female. Higher social isolation score remained significantly associated with self-harm after adjustment (adjusted odds ratio per standard deviation increase 2.92, 95% confidence interval 1.44-5.95) and household size was negatively associated with the outcome (adjusted odds ratio per unit increase 0.54, 95% CI 0.32-0.94).

CONCLUSIONS

More limited social networks were associated with self-harm after adjustment for potential confounders. Enhancing social structure and effective networking of people with self-harm to community resources may be important for self-harm management in Asian societies and elsewhere.

Reducing suicidal ideation: cost-effectiveness analysis of a randomized controlled trial of unguided web-based self-help

Background

Suicidal ideation is highly prevalent, but often remains untreated. The Internet can be used to provide accessible interventions.

Objective

To evaluate the cost-effectiveness of an online, unguided, self-help intervention for reducing suicidal ideation.

Methods

A total of 236 adults with mild to moderate suicidal thoughts, defined as scores between 1-26 on the Beck Scale for Suicide Ideation (BSS), were recruited in the general population and randomized to the intervention (n = 116) or to a waitlist, information-only, control group (n = 120). The intervention aimed to decrease the frequency and intensity of suicidal ideation and consisted of 6 modules based on cognitive behavioral techniques. Participants in both groups had unrestricted access to care as usual. Assessments took place at baseline and 6 weeks later (post-test). All questionnaires were self-report and administered via the Internet. Treatment response was defined as a clinically significant decrease in suicidal ideation on the BSS. Total per-participant costs encompassed costs of health service uptake, participants’ out-of-pocket expenses, costs stemming from production losses, and intervention costs. These were expressed in Euros (€) for the reference year 2009.

Results

At post-test, treatment response was 35.3% and 20.8% in the experimental and control conditions, respectively. The incremental effectiveness was 0.35 − 0.21 = 0.15 (SE 0.06, P = .01). The annualized incremental costs were −€5039 per participant. Therefore, the mean incremental cost-effectiveness ratio (ICER) was estimated to be −€5039/0.15 = −€34,727 after rounding (US −$41,325) for an additional treatment response, indicating annual cost savings per treatment responder.

Conclusions

This is the first trial to indicate that online self-help to reduce suicidal ideation is feasible, effective, and cost saving. Limitations included reliance on self-report and a short timeframe (6 weeks). Therefore, replication with a longer follow-up period is recommended.

Effect of assertive outreach after suicide attempt in the AID (assertive intervention for deliberate self harm) trial: randomised controlled trial

OBJECTIVE

To assess whether an assertive outreach intervention after suicide attempt could reduce the frequency of subsequent suicidal acts, compared with standard treatment.

DESIGN

Randomised, parallel group, superiority trial with blinded outcome assessment.

SETTING

Outpatient intervention at one location at Copenhagen University Hospital, Denmark.

PARTICIPANTS

Patients older than 12 years admitted to regional hospitals in Copenhagen with a suicide attempt within the past 14 days. We excluded patients diagnosed with schizophrenia spectrum disorders and patients living in institutions.

INTERVENTION

Case management through assertive outreach that provided crisis intervention and flexible problem solving. This approach incorporated motivational support and actively assisted patients to scheduled appointments to improve adherence with after-treatment as an add on to standard treatment.

MAIN OUTCOME

Repeated suicide attempt and death by suicide, recorded in medical records and death register at 1-year follow-up.

RESULTS

243 patients were included. During 12 months of follow-up, 20/123 (16%) patients in the intervention group had been registered in hospital records with subsequent suicide attempt, compared with 13/120 (11%) in the control group (odds ratio 1.60, 95% confidence interval 0.76 to 3.38; P=0.22). By contrast, self reported data on new events showed 11/95 (12%) in the intervention group versus 13/74 (18%) in the control group (0.61, 0.26 to 1.46; P=0.27). By imputing missing data on the selfreported outcomes, we estimated 15/123 (12%) events in the intervention group and 23/120 (19%) in the control group (0.69, 0.34 to 1.43; P=0.32).

CONCLUSION

Assertive outreach showed no significant effect on subsequent suicide attempt. The difference in rates of events between register data and self reported data could indicate detection bias.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00700089.

Treatment received, satisfaction with health care services, and psychiatric symptoms 3 months after hospitalization for self-poisoning

BACKGROUND

Patients who self-poison have high repetition and high mortality rates. Therefore, appropriate follow-up is important. The aims of the present work were to study treatment received, satisfaction with health care services, and psychiatric symptoms after hospitalization for self-poisoning.

METHODS

A cohort of patients who self-poisoned (n = 867) over a period of 1 year received a questionnaire 3 months after discharge. The Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), and Generalized Self-Efficacy Scale (GSE) were used. The participation rate was 28% (n = 242); mean age, 41 years; 66% females.

RESULTS

Although only 14% of patients were registered without follow-up referrals at discharge, 41% reported no such measures. Overall, satisfaction with treatment was fairly good, although 29% of patients waited more than 3 weeks for their first appointment. A total of 22% reported repeated self-poisoning and 17% cutting. The mean BDI and BHS scores were 23.3 and 10.1, respectively (both moderate to severe). The GSE score was 25.2. BDI score was 25.6 among patients with suicide attempts, 24.9 for appeals, and 20.1 for substance-use-related poisonings.

CONCLUSIONS

Despite plans for follow-up, many patients reported that they did not receive any. The reported frequency of psychiatric symptoms and self-harm behavior indicate that a more active follow-up is needed.

Exploring Registered Psychiatric Nurses' Responses towards Service Users with a Diagnosis of Borderline Personality Disorder

This study explored registered psychiatric nurses' (RPNs') interactions and level of empathy towards service users with a diagnosis of borderline personality disorder (BPD). A qualitative approach was used, and 17 RPNs were interviewed using a semistructured interview schedule incorporating the “staff-patient interaction response scale” (SPIRS). Four themes emerged following data analysis: “challenging and difficult,” “manipulative, destructive and threatening behaviour,” “preying on the vulnerable resulting in splitting staff and other service users,” and “boundaries and structure.” Additionally, low levels of empathy were evident in the majority of participants' responses to the SPIRS. The findings provide further insight on nurses' empathy responses and views on caring for service users with BPD and further evidence for the need for training and education for nurses in the care of service users diagnosed with BPD.

Problem-solving therapy for people who present to hospital with self-harm: Zelen randomised controlled trial

BACKGROUND

Presentations to hospital with self-harm are common, associated with suicide and have an increased mortality, yet there is no accepted effective intervention.

AIMS

To investigate whether problem-solving therapy would improve outcomes in adults presenting to hospital with self-harm, compared with usual care.

METHOD

A Zelen randomised controlled trial was conducted in four district health boards in New Zealand. A second hospital presentation with self-harm at 1 year for all episodes, plus separate comparisons of first-time and repeat presentations at the index episode, were the a priori primary outcomes. The trial registration number was ACTRN12605000337673.

RESULTS

In an intention-to-treat analysis of all randomised patients (n = 1094) there was no significant difference at 12 months in the proportion of people who had presented again with self-harm when comparing all episodes (intervention 13.4%, usual care 14.1%; relative risk reduction RR = 0.05, 95% CI -0.28 to 0.30, P = 0.79) or where the index episode was the first episode (intervention 13.4%, usual care 9.4%, RR = -0.42, 95% CI -1.17 to 0.08, P = 0.37). Where the index episode was repeated self-harm, those who received therapy were less likely to present again with self-harm (intervention 13.5%, usual care 22.1%, RR = 0.39, 95% CI 0.07 to 0.60, number needed to treat 12, P = 0.03).

CONCLUSIONS

Problem-solving therapy is not recommended for everyone who presents to hospital with self-harm. Among adults with a history of self-harm it may be an effective intervention.

Measuring self-harm in adults: a systematic review

PURPOSE

To identify from the literature, and to critically evaluate, all validated instruments currently available to measure self-harming behaviour in adults.

MATERIALS AND METHODS

Medline, Embase, PsycInfo, Health and Psychosocial Instruments and Google scholar were searched, grey literature was sought and the reference lists of relevant articles were checked to identify instruments.

RESULTS

A total of seven validated instruments which met our inclusion criteria were identified and data were extracted regarding each instrument's format, administration method, psychometric properties and number of items and domains included. Considerable variation was observed in the overall quality of these instruments. Fourteen other instruments were identified which did not describe their psychometric properties or had not been published and were subsequently excluded from our review.

DISCUSSION

Although many instruments were identified in our search, only a small number had been validated with published psychometric properties. Of the identified instruments, the Suicide Attempt Self-Injury Interview (SASII) appears to be the most robust and comprehensive instrument currently available. Despite the absence of psychometric data, numerous other instruments have been used in published studies, including clinical trials.

CONCLUSION

Our results highlight the pressing need for a standardized, empirically validated and versatile measure of intentional self-harming behaviour for use in both clinical and research settings. The optimum characteristics of such an instrument are discussed.

All-cause mortality after non-fatal self-poisoning: a cohort study

BACKGROUND

Suicide has been repeatedly shown to have greatly increased incidence after non-fatal self-harm but far less is known about early death from other causes. The present study's aim was to describe mortality and risk factors concerning all causes of death after non-fatal self-poisoning.

METHODS

A prospective cohort study of 976 patients who attended the Emergency Department in Nottingham, UK during a 9-month period in 1985-1986. Information on deaths was obtained for 16 years following an episode of self-poisoning, from the records of the Office for National Statistics.

RESULTS

The observed:expected ratio for all-cause mortality was 2.2. Deaths due to diseases of the digestive and respiratory systems were, respectively, 4.4 and 2.9 times more frequent than expected. The risk for accidents was sixfold and for probable suicides 17-fold when compared with the risk in the general population. The main risk factor for subsequent deaths from natural causes was increasing age.

CONCLUSIONS

The findings of this study suggest that patients who survive self-poisoning have an increased risk of death from natural and unnatural causes. The findings point towards the need for more effective clinical management and preventive initiatives.