Psychosocial interventions for adults who self-harm

We have reviewed the interventional literature regarding psychosocial intervention treatment trials in the field. A total of 76 trials meeting our inclusion criteria were identified. There may be beneficial effects for psychological therapy based on cognitive behavioural therapy (CBT) approaches at longer follow-up time points, and for mentalisation-based therapy (MBT), and emotion-regulation psychotherapy at the post-intervention assessment. There may also be some evidence of effectiveness of standard dialectical behaviour therapy (DBT) on frequency of SH repetition. There was no clear evidence of effect for case management, information and support, remote contact interventions (e.g. emergency cards, postcards, telephone-based psychotherapy), provision of information and support, and other multimodal interventions.

Why is this review important?

Self-harm (SH), which includes intentional self-poisoning/overdose and self-injury, is a major problem in many countries and is strongly linked with suicide. It is therefore important that effective treatments are developed for people who engage in SH. There has been an increase in both the number of trials and the diversity of therapeutic approaches for SH in adults in recent years. It is therefore important to assess the evidence for their effectiveness.

Who will be interested in this review?

Hospital administrators (e.g. service providers), health policy officers and third party payers (e.g. health insurers), clinicians working with people who engage in SH, the people themselves, and their relatives.

What questions does this review aim to answer?

This review is an update of a previous Cochrane review from 2016 which found that CBT-based psychological therapy can result in fewer individuals repeating SH whilst DBT may lead to a reduction in frequency of repeated SH. This updated review aims to further evaluate the evidence for effectiveness of psychosocial interventions for people engaging in 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.

What does the evidence from the review tell us?

Overall, there were a number of methodological limitations across the trials included in this review. We found positive effects for psychological therapy based on CBT approaches at longer follow-up assessments, and for mentalisation-based therapy (MBT), and emotion-regulation psychotherapy on repetition of SH at post-intervention. There may also be some evidence of effects for standard dialectical behaviour therapy (DBT) on frequency of SH repetition. However, remote contact interventions, case management, information and support, and other multimodal interventions do not appear to have benefits in terms of reducing repetition of SH.

What should happen next?

The promising results for CBT-based psychotherapy at longer follow-up time points, and for MBT, group-based emotion regulation, and DBT warrant further investigation to understand which people benefit from these types of interventions. Greater use of head-to-head trials (where treatments are directly compared with each other) may also assist in identifying which component(s) from these often complex interventions may be most effective.

Authors' conclusions: 

Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.

Read the full abstract...
Background: 

Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults.

Objectives: 

To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH.

Search strategy: 

We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).

Selection criteria: 

We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.

Data collection and analysis: 

We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach.

Main results: 

We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions.

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