The use of emergency department-based psychological interventions to reduce repetition of self-harm behaviour
Authors: Katrina Witt
Journal: The Lancet Psychiatry (2017)

Suicide is a public health emergency; over 800 000 people take their life each year,1WHOPreventing suicide: a global imperative. World Health Organization, Geneva2014Google Scholar and by 2020, this figure is projected to rise to 1·53 million.2Bertolote JM Fleischmann A Suicide and psychiatric diagnosis: a worldwide perspective.World Psychiatry. 2002; 1: 181-185PubMed Google Scholar Yet, for each suicide, an estimated 26·2 additional people present to hospital with self-harm.3Hawton K Harriss L How often does deliberate self-harm occur relative to each suicide? A study of variations by gender and age.Suicide Life Threat Behav. 2008; 38: 650-660Crossref PubMed Scopus (80) Google Scholar The prevention of self-harm is therefore highlighted within most countries' national suicide prevention strategy. There is good evidence to suggest that certain outpatient psychological treatments, and particularly cognitive behavioural therapy (CBT), are effective in reducing repetition of self-harm and, to a lesser extent, suicide.4Hawton K Witt KG Taylor Salisbury TL et al.Psychosocial interventions for self-harm in adults.Cochrane Database Syst Rev. 2016; 5 (CD012189)Crossref Scopus (120) Google Scholar Because of resourcing limitations, however, patients often face delays of up to several weeks before their first appointment; even in countries with well-resourced psychiatric services.5Erlangsen A Lind BD Stuart EA et al.Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching.Lancet Psychiatry. 2015; 2: 49-58Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar Yet almost half of all patients who repeat self-harm will do so in this period.6Perry IJ Corcoran P Fitzgerald AP Keeley HS Reulbach U Arensman E The incidence and repetition of hospital-treated deliberate self-harm: findings from the world's first national registry.PLoS One. 2012; 7: e31663Crossref PubMed Scopus (131) Google Scholar There is therefore substantial interest in the development of brief interventions that can be delivered while patients are receiving medical treatment in the emergency department. Rory O'Connor and colleagues' randomised controlled trial of a volitional help-sheet (VHS), reported in The Lancet Psychiatry,7O'Connor RC Ferguson E Scott F et al.A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: a randomised controlled trial.Lancet Psychiatry. 2017; (published online April 20)http://dx.doi.org/10.1016/S2215-0366(17)30129-3PubMed Google Scholar represents a timely addition to this literature. Importantly, the VHS signals a departure from other emergency department-based interventions which, to date, have focused on the effectiveness of safety-planning and psychosocial risk or needs assessments alone.8Betz ME Wintersteen M Boudreaux ED et al.Reducing suicide risk: opportunities in the emergency department.Ann Emerg Med. 2016; 68: 758-765Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar Intention-to-treat analyses including all 518 randomised participants revealed that the VHS was not associated with a reduction in either the proportion of participants repeating self-harm, the number of repeated self-harm episodes, or the time to self-harm repetition in this trial. Post-hoc subgroup analyses including 507 participants who completed the trial, however, were suggestive of some, albeit non-significant, evidence of benefit in reducing the proportion of participants repeating self-harm as well as a significant reduction in the number of self-harm episodes in those with a history of self-harm. By contrast, in patients without a history of multiple episodes of self-harm, there was evidence the VHS might be harmful, suggesting that careful targeting of this intervention is required. These subgroup findings, although consistent with accumulating research evidence,4Hawton K Witt KG Taylor Salisbury TL et al.Psychosocial interventions for self-harm in adults.Cochrane Database Syst Rev. 2016; 5 (CD012189)Crossref Scopus (120) Google Scholar require replication. The VHS is grounded in an empirical theoretical rationale in which the authors hypothesise that behavioural intentions represent the key conduit between suicidal ideation and enaction.9Dhingra K Boduszek D O'Connor RC Differentiating suicide attempters from suicide ideators using the integrated motivational-volitional model of suicidal behaviour.J Affect Disord. 2015; 186: 211-218Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar Although the VHS was effective in reducing self-reported self-harm intentions in a previous trial,10Armitage CJ Rahim WA Rowe R O'Connor RC An exploratory randomised trial of a simple, brief psychological intervention to reduce subsequent suicidal ideation and behaviour in patients admitted to hospital for self-harm.Br J Psychiatry. 2016; 208: 470-476Crossref PubMed Scopus (35) Google Scholar the intervention was not effective in reducing the proportion of participants engaging in self-harming behaviour in this trial. This would suggest that further articulation of the mechanisms underpinning the VHS is warranted. Without delineation of the potential mechanisms of action of this intervention, alongside greater use of mediational analyses to investigate the extent to which the VHS results in actual change to these hypothesised mechanisms, it is difficult to know whether the intervention can, in fact, lead to lasting changes to the putative psychological processes that lead from suicidal ideation to action. Brief psychological interventions that require minimal expertise to deliver hold promise for improving the reach and scalability of evidence-based treatments for self-harm; particularly for low-income to middle-income countries with constrained resources. However, these interventions also have the potential to increase rumination and negative affect, and potentially self-harm repetition, by serving as unhelpful reminders of negative experiences in the lead-up to the index self-harm event or during hospital treatment. Despite this observation, few trials have assessed the effect of interventions such as the VHS on these processes. A consensus standard of definitions of outcomes for benefit, harm, and cost-effectiveness is needed to enhance this evidence base. Outcome standardisation would also help to improve comparability between trials in this field in the future. I declare no completing interests. A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: a randomised controlled trialFor the primary outcomes, there were no significant differences between groups. Although the VHS had no overall effect, post-hoc analyses suggest VHS might be effective in reducing the number of self-harm repetitions following a suicide attempt in people who complete the helpsheet and who have been previously admitted to hospital with self-harm. This is the first study to investigate the usefulness of the VHS to reduce self-harm among those who have attempted suicide. These subgroup findings require replication. Full-Text PDF Open Access