Psychosocial interventions for self-harm in adults

Why is this review important?

Self harm (SH), which includes non-fatal intentional self-poisoning/overdose and self-injury, is a major problem in many countries and is linked to risk of future suicide. It is distressing for both patients and their families and friends, and places large demands on clinical services. It is therefore important to assess the evidence on treatments for SH patients.

Who will be interested in this review?

Clinicians working with people who engage in SH, policy makers, people who themselves have engaged in SH or may be at risk of doing so, and their families and relatives.

What questions does this review aim to answer?

This review is an update of a previous Cochrane review from 1999, which found little evidence of beneficial effects of psychosocial treatments on repetition of SH. This update aims to further evaluate the evidence for the effectiveness of psychosocial treatments for patients with SH with a broader range of outcomes.

Which studies were included in the review?

To be included in the review, studies had to be randomised controlled trials of psychosocial interventions for adults who had recently engaged in SH. We searched electronic databases to find all such trials published up until 29 April 2015, and found 55 that met our inclusion criteria.

What does the evidence from the review tell us?

There have now been a number of investigations of psychosocial treatments for SH in adults, with greater representation in recent years of low- and middle-income countries such as China, Iran, Pakistan, and Sri Lanka.

Some moderate quality evidence shows that cognitive-behavioural-based (CBT-based) psychotherapy (a psychotherapy intended to change unhelpful thinking, emotions and behaviour) may help prevent repetition of SH, although it did not reduce overall frequency of SH. There were encouraging results (from small trials of moderate to very low quality) for other interventions aimed at reducing the frequency of SH in people with probable personality disorder, including group-based emotion-regulation psychotherapy, mentalisation (a psychosocial therapy intended to increase a person’s understanding of their own and others' mental state), and dialectical behaviour therapies (DBT; psychosocial therapies intended to assist with identification of triggers that lead to reactive behaviours and to provide individuals with emotional coping skills to avoid these reactions). Whilst DBT was not associated with a significant reduction in repetition of SH at final follow-up as compared to usual treatment, there was evidence of low quality suggesting a reduction in frequency of SH.

There was no clear evidence supporting the effectiveness of prolonged exposure to DBT, case management, approaches to improve treatment adherence, mixed multimodal interventions (comprising both psychological therapy and remote contact-based interventions), remote contact interventions (postcards, emergency cards, and telephone contact), interpersonal problem-solving skills training, behaviour therapy, provision of information and support, treatment for alcohol misuse, home-based problem-solving therapy, intensive inpatient and community treatment, general hospital admission, intensive outpatient treatment, or long-term psychotherapy.

We had only limited evidence from a subset of the studies relating to whether the intervention had different effects in men and women. The trials did not report on side effects other than suicidal behaviour.

What should happen next?

The promising results for CBT-based psychological therapy and dialectical behaviour therapy warrant further investigation to understand which patients benefit from these types of interventions. There were only a few, generally small trials on most other types of psychosocial therapies, providing little evidence of beneficial effects; however, these cannot be ruled out. There is a need for more information about whether psychosocial interventions might work differently between men and women.

Authors' conclusions: 

CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.

Read the full abstract...
Background: 

Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.

Objectives: 

To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.

Search strategy: 

The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

Selection criteria: 

We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.

Data collection and analysis: 

We used Cochrane's standard methodological procedures.

Main results: 

We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.

There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).

For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.

Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).

None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.

We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported.

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