Abstract
Introduction
The lifetime prevalence of deliberate self-harm is about 3% to 5% of the population in Europe and the USA, and has been increasing. Familial, biological, and psychosocial factors may contribute. Risks are higher in women and young adults, people who are socially isolated or deprived, and people with psychiatric or personality disorders.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for deliberate self-harm in adolescents and adults? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2006 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: cognitive therapy; continuity of care; dialectical behavioural therapy; emergency card; flupentixol depot injection; general practice-based guidelines; hospital admission; intensive outpatient follow-up plus outreach; mianserin; nurse-led case management; oral antipsychotics; paroxetine; problem-solving therapy; psychodynamic interpersonal therapy; and telephone contact.
Key Points
Deliberate self-harm involves acts such as self-cutting or self-poisoning, carried out deliberately, with or without the intention of committing suicide.
Lifetime prevalence of deliberate self-harm in Europe and the USA is about 3% to 5% of the population, and is increasing.
Familial, biological and psychosocial factors may contribute. Risks are higher in women and young adults, in people who are socially isolated or deprived, and those with psychiatric or personality disorders.
Around a quarter of people will repeat the self-harm within 4 years, and the long-term suicide risk is 3% to 7%.
Younger adults are more likely to repeat non-fatal self-harm, while adults aged over 45 years are more likely to commit suicide, especially if the previous self-harm involved a violent method.
No pharmaceutical treatments have been clearly shown to be of benefit in reducing recurrent self-harm.
It is possible that flupentixol depot injections may reduce the recurrence of self-harm, but with associated adverse effects.
Mianserin does not seem to reduce recurrence rates, but we don't know this for certain.
CAUTION: Paroxetine has not been shown to reduce the risks of repeated deliberate self-harm and may increase suicidal ideation and congenital malformations.
The effects of psychological treatments are also unclear.
Problem-solving therapy may reduce depression and anxiety, but may not be effective in preventing recurrence of self-harm.
Evidence for benefit from cognitive therapy or psychodynamic interpersonal therapy compared with usual care is unclear.
Intensive follow-up plus outreach, nurse-led management, emergency card, general practice-based guidelines and hospital admission have not been shown to reduce recurrent self-harm compared with usual care.
About this condition
Definition
Deliberate self-harm is an acute non-fatal act of self-harm carried out deliberately in the form of an acute episode of behaviour by an individual with variable motivation. The intention to end life may be absent or present to a variable degree. Other terms used to describe this phenomenon are “attempted suicide” and “parasuicide”. For the purpose of this review, the term deliberate self-harm will be used throughout. Common methods of deliberate self-harm include self-cutting, and self-poisoning, for example by overdosing on medicines. Some acts of deliberate self-harm are characterised by high suicidal intent, meticulous planning (including precautions against being found out), and severe lethality of the method used. Other acts of deliberate self-harm are characterised by no or low intention of suicide, lack of planning and concealing of the act, and low lethality of the method used. The related term of “suicide” is defined as an act with a fatal outcome, deliberately initiated and performed by the person with the knowledge or expectation of its fatal outcome. This review focuses on the literature in people aged at least 15 years who present with an episode of deliberate self-harm as the main presenting problem and where this is the main (primary) sample selection and outcome criterion for the RCTs. However, some people thus selected may have other accompanying conditions, such as borderline personality disorder or depression, which are considered as secondary criteria and outcomes. The review excludes RCTs where the main (primary) sample selection criterion is not deliberate self harm but some other condition such as depression or borderline personality disorder, even though such trials may study deliberate self harm as a secondary criterion and outcome. Deliberate self-harm is not defined in the DSM-IV or the ICD-10.
Incidence/ Prevalence
Based on data from 16 European countries between 1989 and 1992, the lifetime prevalence of deliberate self-harm in people treated in hospital and other medical facilities, including general practice settings, is estimated at about 3% for women and 2% for men. Over the last 50 years there has been a rise in the incidence of deliberate self-harm in the UK. A reasonable current estimate is about 400/100,000 population a year. In two community studies in the USA, 3% to 5% of responders said that they had made an attempt at deliberate self-harm at some time. Self-poisoning using organophosphates is particularly common in resource-poor countries. A large hospital (catering for 900,000 people) in Sri Lanka reported 2559 adult hospital admissions and 41% occupancy of medical intensive care beds for deliberate self-harm with organophosphates over 2 years. An international survey using representative community samples of adults (aged 18–64 years) reported lifetime prevalence of self-reported deliberate self-harm of 3.82% in Canada, 5.93% in Puerto Rico, 4.95% in France, 3.44% in West Germany, 0.72% in Lebanon, 0.75% in Taiwan, 3.2% in Korea, and 4.43% in New Zealand.
Aetiology/ Risk factors
Familial, biological, and psychosocial factors may contribute to deliberate self-harm. Evidence for genetic factors include a higher risk of familial suicide, and greater concordance in monozygotic than dizygotic twins for deliberate self-harm. Evidence for biological factors includes reduced cerebrospinal fluid 5-hydroxyindoleacetic acid levels and a blunted prolactin response to the fenfluramine challenge test, indicating a reduction in the function of serotonin in the central nervous system. People who deliberately self-harm also show traits of impulsiveness and aggression, inflexible and impulsive cognitive style, and impaired decision making and problem solving. Deliberate self-harm is more likely to occur in: women; young adults; people who are single or divorced; people with low education level; unemployed people; disabled people; people suffering from a psychiatric disorder (particularly depression); people with substance-misuse problems; people with borderline and antisocial personality disorders; people with severe anxiety disorders; and people with physical illness. A study based on a prospectively collected self-harm register from inner-city Manchester, UK, showed that the incidence of self-harm was positively correlated with area-level deprivation and unemployment. Further analysis using logistic regression modelling found that repetition of self-harm within the first 6 months was associated with factors such as a person's previous history of self-harm, being unemployed or registered sick, marital status (being single, separated, divorced, or widowed), or living in an area with a lower percentage of white population. However, a person’s own ethnicity was not a distinguishing factor. In adults, SSRIs have been thought to be associated with an increased risk of suicidal behaviour compared with placebo, but not compared with tricyclic antidepressants.
Prognosis
Suicide is highest during the first year after deliberate self-harm. One systematic review found median rates of repetition of 16% (interquartile range [IQR] 12–25%) within the first year, 21% (IQR 12% to 30%) within 1 to 4 years, and 23% (IQR 11% to 32%) within 4 years or longer. It found median mortality from suicide after deliberate self-harm of 1.8% (IQR 0.8% to 2.6%) within the first year, 3.0% (IQR 2.0% to 4.4%) within 1 to 4 years, 3.4% (IQR 2.5% to 6.0%) within 5 to 10 years, and 6.7% (IQR 5.0% to 11.0%) within 9 years or longer. Repetition of deliberate self-harm is more likely in people where the following factors are present: aged 25 to 49 years; unemployment; divorce; socio-economic disadvantage; history of substance misuse; depression; hopelessness; powerlessness; personality disorders; unstable living conditions or living alone; criminal record; previous psychiatric treatment; history of stressful traumatic life events; and history of coming from a broken home or of family violence. Factors associated with risk of suicide after deliberate self-harm are: being aged over 45 years; male sex; being unemployed, retired, separated, divorced, or widowed; living alone; having poor physical health; having a psychiatric disorder (particularly depression, alcoholism, schizophrenia, and sociopathic personality disorder); high suicidal intent in current episode including leaving a written note; violent method used in current episode; and history of previous deliberate self-harm.
Aims of intervention
To reduce repetition of deliberate self-harm; to reduce desire to self-harm; to prevent suicide; and to improve social functioning and quality of life, with minimal adverse effects.
Outcomes
Repetition of deliberate self-harm (includes repetition rate, occurrence of suicide, and admission to hospital), improvement in underlying psychiatric symptoms (includes improvement in coping), quality of life, and adverse effects. Some of the validated scales used for assessing psychiatric symptoms and deliberate self-harm are: Symptom Checklist-90 (SCL-90), which is a self-administered rating scale for assessing nine areas of psychopathology (somatisation, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic-anxiety, paranoid ideation, and psychoticism); Beck Depression Inventory (a 21-item self-administered Likert scale for measuring severity of depression); Hospital Anxiety Depression Scale (a self-administered 14-item Likert scale for measuring depression and anxiety); Beck Scale for Suicidal Ideation (a 21-item self-administered Likert scale covering thoughts and plans about suicide that aims at assessing the risk of a later suicide attempt); Beck Hopelessness Scale (a 20-item true–false self-administered scale that aims at assessing hopelessness about the future); and Global Severity Index (GSI; a mean of all items in SCL-90).
Methods
Clinical Evidence search and appraisal October 2006. The following databases were used to identify studies for this review: Medline 1966 to October 2006, Embase 1980 to October 2006, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2006, Issue 3. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and NICE. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies are then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs, and clustered trials in any language, including open trials, and containing more than 20 people of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. Searches were performed for all antidepressants, antipsychotics, anxiolytics, antiepileptics, cognitive therapies, lithium, and mood stabilisers; but only those that yielded RCTs of sufficient quality were described. Trials were excluded if less than 51% of the population was aged 15 years or over. We also conducted a harms search for observational studies on SSRI use and increased suicide risk. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the review as required. To aid readability of the numerical data in our reviews, we round percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as RRs and ORs. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table.
GRADE Evaluation of interventions for Deliberate self-harm (and attempted suicide).
| Important outcomes | Adverse effects, Improvement in underlying psychiatric symptoms, Quality of life, Repetition of deliberate self-harm | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of treatments for deliberate self-harm in adolescents and adults? | |||||||||
| 1 (120) | Repetition of deliberate self-harm | Cognitive therapy plus usual care versus usual care | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (120) | Improvement in underlying psychiatric symptoms | Cognitive therapy plus usual care versus usual care | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data, lack of blinding, and incomplete reporting of results. Consistency point deducted for lack of consistent benefit (conflicting results using different scales) |
| 1 (141) | Repetition of deliberate self-harm | Continuity of care | 4 | –1 | 0 | –1 | +1 | Moderate | Quality point deducted for sparse data. Directness point deducted for high prevalence of risk factors in same therapist group. Effect-size point added for RR 2–5 |
| 2 (317) | Repetition of deliberate self-harm | Emergency card versus standard care | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for inclusion of children under 15 years and differences in interventions compared between groups |
| 1 (30) | Repetition of deliberate self-harm | Flupentixol depot injection versus placebo | 4 | –2 | 0 | 0 | +1 | Moderate | Quality points deducted for sparse data and no intention-to-treat analysis. Effect-size point added for RR <0.5 |
| 1 (77) | Repetition of deliberate self-harm | Hospital admission versus immediate discharge | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (114) | Repetition of deliberate self-harm | Mianserin versus placebo | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for sparse data. Directness points deducted for uncertainty about generalisability of results and for inclusion of nomifensine |
| 1 (467) | Repetition of deliberate self-harm | Nurse-led case management versus usual care | 4 | 0 | 0 | 0 | 0 | High | |
| 1 (91) | Repetition of deliberate self-harm | Paroxetine versus placebo | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for co-intervention |
| 1 (91) | Adverse effects | Paroxetine versus placebo | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for co-intervention |
| 5 (571) | Repetition of deliberate self-harm | Problem-solving therapy versus usual care | 4 | 0 | 0 | –1 | 0 | Moderate | Directness point deducted for differences in disease severity between groups |
| 6 (at least 158) | Improvement in underlying psychiatric symptoms | Problem-solving therapy versus usual care | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for uncertainty about methods of assessing improvement |
| 1 (119) | Repetition of deliberate self-harm | Psychodynamic interpersonal therapy versus usual care | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (119) | Improvement in underlying psychiatric symptoms | Psychodynamic interpersonal therapy versus usual care | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (777) | Repetition of deliberate self-harm | Telephone contact versus usual care | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, no intention-to-treat analysis, and for methodological limitations. Consistency point deducted for conflicting results at different end points |
| 1 (172) | Improvement in underlying psychiatric symptoms | Telephone contact versus usual care | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and for no intention-to-treat analysis |
| 1 (1932) | Repetition of deliberate self-harm | General practice-based guidelines versus usual care | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for not accounting for effects of cluster randomisation. Directness point deducted for multiple interventions |
| 6 (1161) | Repetition of deliberate self-harm | Intensive outpatient follow-up plus outreach versus usual care | 4 | 0 | 0 | 0 | 0 | High | |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Glossary
- Beck Depression Inventory
Standardised scale to assess depression. This instrument consists of 21 items to assess the intensity of depression. Each item is a list of 4 statements (rated 0, 1, 2, or 3), arranged in increasing severity, about a particular symptom of depression. The range of scores possible are 0 = least severe depression to 63 = most severe depression. It is recommended for people aged 13 to 80 years. Scores of more than 12 or 13 indicate the presence of depression.
- Case management
Involves a case manager managing an individual's care including comprehensive assessment of their needs, development of individualised package of care, the arrangement of access to services, monitoring of quality of services provided, and long-term flexible support.
- Cognitive therapy
A form of psychotherapy aimed at correcting distorted thinking and beliefs responsible for maintaining the disorder by use of Socratic questioning, logical arguments, and empirical testing of beliefs.
- Crisis intervention
Involves short-term help with current and acute difficult life events using variety of counselling, problem solving, and practical measures.
- Hamilton Depression Rating Scale
a measure of depressive symptoms using 17 items, with total scores from 0 to 54 (higher scores indicate increased severity of depression).
- High-quality evidence
Further research is very unlikely to change our confidence in the estimate of effect.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Motivational interviewing
Uses principles of motivational psychology and is aimed at helping people to change and engage in demanding treatments.
- Problem-solving therapy
Uses a set of sequential steps in solving problems and aims at minimising negative emotion and maximising identification, evaluation, and implementation of optimal solutions.
- Psychodynamic interpersonal therapy
A psychotherapeutic intervention aimed at improving interpersonal problems using the model developed by Hobson.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
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