Abstract
Introduction
The lifetime prevalence of deliberate self-harm is about 3% to 5% of the population in Europe and the US, 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 non-pharmacological treatments for deliberate self-harm in adolescents and adults? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2013 (BMJ 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
Twenty-two studies were included. 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; hospital admission; intensive outpatient follow-up plus outreach; nurse-led case management; 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 suicide.
Lifetime prevalence of deliberate self-harm in Europe and the US is about 3% to 5% of the population, and has been 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 in 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 die by suicide, especially if the previous self-harm involved a violent method.
Interventions for the treatment of deliberate self-harm may include pharmacological and non-pharmacological therapies. For this review, we have focused on non-pharmacological treatments only. We assessed outcomes of repetition of deliberate self-harm, improvement in underlying psychiatric symptoms, quality of life, and adverse effects.
We searched for evidence from RCTs and systematic reviews of RCTs.
The effects of psychological treatments following deliberate self-harm are unclear.
Problem-solving therapy may reduce depression and hopelessness but it does not seem to be effective at preventing recurrence of self-harm, although one RCT found limited evidence of benefit in people whose index episode was a repeat of self-harm.
Evidence for benefit from cognitive therapy, psychodynamic interpersonal therapy, or telephone contact following deliberate self-harm compared with usual care is unclear.
Two RCTs of low quality found that cognitive therapy plus usual care reduces repetition of deliberate self-harm and improves some underlying symptoms compared with usual care alone.
We were unable to find any evidence from RCTs meeting our inclusion criteria on the effects of dialectical behavioural therapy in people following deliberate self-harm.
One large multicentre trial found brief intervention and contact (a form of intensive follow-up plus outreach) may be more effective at decreasing death from suicide in people presenting to the emergency department following an episode of deliberate self-harm compared with treatment as usual.
However, intensive follow-up plus outreach may not reduce recurrent self-harm compared with usual care.
Nurse-led management, emergency card, and hospital admission have not been shown to reduce recurrent self-harm compared with usual care.
We found insufficient evidence on the effect of follow-up with the same therapist after hospital treatment for deliberate self-harm compared with follow-up with a different therapist (continuity of care).
Clinical context
General background
The lifetime prevalence of deliberate self-harm is about 3% to 5% of the population in Europe and the US, and has been increasing. This condition could be repetitive in up to 23% of people over 4 years, and could lead to death by suicide in up to 8% of the people over 9 years. In addition, deliberate self-harm is associated with higher rates of death from non-suicidal causes. Both pharmacological and non-pharmacological approaches to treatment have been investigated.
Focus of the review
Non-pharmacological interventions are more often used compared with pharmacological approaches, which are either ineffective or inadequately investigated. Also, there has been more research into non-pharmacological approaches; thus, these are the focus of this review.
Comments on evidence
The quality of evidence for most interventions was not good, being either low or moderate using GRADE evaluation.
Search and appraisal summary
The update literature search for this review was carried out from the date of the last search, October 2006, to August 2013. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the review, please see the Methods section. Searching of electronic databases retrieved 729 studies. After deduplication and removal of conference abstracts, 174 records were screened for inclusion in the review. Appraisal of titles and abstracts led to the exclusion of 130 studies and the further review of 44 full publications. Of the 44 full articles evaluated, no systematic reviews and six RCTs were added at this update (two of which were added to the Comment sections). In addition, manual review of the reference list of one study led to the identification of two separate reports on the same RCT and data are reported from these studies.
Additional information
Effectiveness for any of the interventions reviewed is unproven from RCTs. However, people presenting with deliberate self harm are a heterogeneous group; therefore some of the interventions may be used depending on a patient’s individual needs or previous experience with a particular patient.
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 (e.g., 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 (with or without suicidal intent) 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. The DSM-5 defines ‘suicidal behaviour disorder’ and ‘nonsuicidal self-injury’ (NSSI) as conditions for further research. In the ‘suicidal behaviour disorder’ an individual has made at least one suicide attempt in the last 24 months, where 'suicide attempt' is further defined as a self-initiated sequence of behaviours by an individual who at the time of initiation expected that the set of actions would lead to his or her own death. Conversely, NSSI is defined as intentional self-inflicted damage to the surface of the body of a sort that is likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that injury will only lead to minor or moderate physical harm (i.e., there is no suicidal intent). However, these DSM-5 definitions do not cover the situation where self-poisoning is carried out with no suicidal intent.
Incidence/ Prevalence
Based on the 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. A subsequent WHO/Euro survey carried out from 1995 to 1999 showed annual rates for females to be between 83/100,000 per year (in Italy) and 433/100,000 per year (in the UK); and for males to be 53/100,000 per year (in Sweden) to 337/100,000 per year (in the UK). The trend between the two surveys showed that there was an average decrease of 13% in men and 4% in women. However, over the last 50 years, there has been a longer-term trend showing 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 the two community studies in the US, 3% to 5% of responders said that they had made an attempt at deliberate self-harm at some time. The US National Comorbidity Survey (carried out from 1990–1992 using a nationally representative sample of 5,877 respondents, aged between 15–54 years) showed prevalence of suicide attempts as 2.7% and suicide gestures as 1.9% — the former were characterised by male sex, fewer years of education, psychiatric diagnoses (including depressive, impulsive, and aggressive symptoms), and history of multiple physical and sexual assaults. An international survey using representative community samples of adults (aged 18–64 years) reported lifetime prevalence of self-reported deliberate self-harm of 3.8% in Canada, 5.9% in Puerto Rico, 5.0% in France, 3.4% in West Germany, 0.7% in Lebanon, 0.8% in Taiwan, 3.2% in Korea, and 4.4% in New Zealand. WHO carried out a multi-site survey in 2004 of random samples (n = 500 to 8794) of the general population of one city each in 10 countries and found the following lifetime prevalence of attempted suicide: Brazil 3.1%, China 2.4%, Estonia 3.6%, India 1.6%, Iran 4.2%, South Africa 3.4%, Sri Lanka 2.1%, Vietnam 0.4%, Australia 4.2%, and Sweden 4.0%. 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.
Aetiology/ Risk factors
Familial, biological, and psychosocial factors may contribute to deliberate self-harm. Evidence for genetic factors includes 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. Other features suggested are emotional dysregulation, hopelessness, and over-general memory (i.e., problem with autobiographical memory preventing recall of reasons for living). 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%–30%) within 1 to 4 years, and 23% (IQR 11%–32%) within 4 years or longer. It found median mortality from suicide after deliberate self-harm of 1.8% (IQR 0.8%–2.6%) within the first year, 3.0% (IQR 2.0%–4.4%) within 1 to 4 years, 3.4% (IQR 2.5%–6.0%) within 5 to 10 years, and 6.7% (IQR 5.0%–11.0%) within 9 years or longer. The DSM-5 estimates that 20% to 30% of suicide attempters go on to make more attempts. 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. Other factors relevant to repetition are previous attempts, history of violence, and being single or separated. 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. Also, the rate of non-suicidal death is higher in those with a history of attempted suicide; three cohort studies reported higher rates of non-suicidal deaths. The first cohort study investigated 302 people over 5 years and showed that deaths by motor vehicle accidents were 12 times higher than the expected. The second study investigated 4044 people over 10 years and showed that standardised mortality ratio for non-accidental death was 4.98 (95% CI 4.08 to 6.07). The third study investigated 1083 people over 4 to 7 years and showed standardised mortality ratio for non-suicidal mortality was 4.7.
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); Global Severity Index (GSI; a mean of all items in SCL-90); Suicide cognition scale (a measure of suicidal ideas); and Robsons self concept questionnaire (a measure of self-esteem and a person’s attitude towards him- or herself).
Methods
BMJ Clinical Evidence search and appraisal August 2013. The following databases were used to identify studies for this review: Medline 1966 to August 2013, Embase 1980 to August 2013, and The Cochrane Database of Systematic Reviews 2013, issue 8 (1966 to date of issue). Additional searches were carried out in the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment (HTA) database. We also searched for retractions of studies included in the review. Titles and abstracts identified by the initial search, run by an information specialist, were first assessed against predefined criteria by an evidence scanner. Full texts for potentially relevant studies were then assessed against predefined criteria by an evidence analyst. Studies selected for inclusion were discussed with an expert contributor. All data relevant to the review were then extracted. Study design criteria for inclusion in this review were: published RCTs and systematic reviews of RCTs in the English language, any level of blinding, including those described as 'open', 'open label', or unblinded, and containing at least 20 individuals (at least 10 per arm) of whom at least 80% were followed up. There was no minimum length of follow-up. We included studies where at least 51% of the population were aged 15 years or over and whose main presenting problem/primary diagnosis or inclusion criterion was recent deliberate self-harm/attempted suicide. We excluded studies focused only on suicidal ideation, as this is beyond the scope of the review. We included RCTs and systematic reviews of RCTs where harms of an included intervention were assessed, applying the same study design criteria for inclusion as we did for benefits. 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 | 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 non-pharmacological treatments for deliberate self-harm in adolescents and adults? | |||||||||
| 2 (197) | Repetition of deliberate self-harm | Cognitive therapy plus usual care versus usual care | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, lack of blinding, incomplete reporting of results, and comparison not described in 1 study |
| 2 (197) | 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, and comparison not described in one study; 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 OR 2–5 |
| 2 (317) | Repetition of deliberate self-harm | Emergency card versus standard care | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for inclusion of children under 15 years and differences in interventions compared between groups |
| 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 (467) | Repetition of deliberate self-harm | Nurse-led case management versus usual care | 4 | 0 | 0 | 0 | 0 | High | |
| 6 (1665) | 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 |
| at least 4 (at least 211) | 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 |
| 9 (3131) | Repetition of deliberate self-harm | Intensive outpatient follow-up plus outreach versus usual care | 4 | 0 | 0 | –2 | 0 | Low | Directness points deducted for differences in active and usual treatment interventions between and within studies, and diverse trial settings |
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 a 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.
Contributor Information
G. Mustafa Soomro, Solent NHS Trust, St James Hospital, Portsmouth, UK.
Sara Kakhi, Wessex Psychiatric Training Scheme, Wessex Deanery, Otterbourne, Winchester, UK.
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