Cochrane has published several reviews of the effects of interventions to reduce self-harm and suicide and, in the first few months of 2021, three of these were updated covering pharmacological and psychosocial interventions for self-harm in children, adolescents and adults. We asked two of the authors, Keith Hawton and Katrina Witt to tell us about the findings in this podcast.
Note: This recording covers three reviews:
- Interventions for children and adolescents who self-harm
- Psychosocial interventions for adults who self-harm
- Drugs and natural products for self-harm in adults
Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Cochrane has published several reviews of the effects of interventions to reduce self-harm and suicide and, in the first few months of 2021, three of these were updated covering pharmacological and psychosocial interventions for self-harm in children, adolescents and adults. We asked two of the authors, Keith Hawton and Katrina Witt to tell us about the findings in this podcast.
Katrina: The focus of this podcast is on improving effective treatments for people who engage in self-harm. Therefore, before we begin, we would like to acknowledge that this podcast discusses topics around self-harm and suicide, which some listeners might find triggering or distressing.
Keith: We’d like to first of all introduce ourselves. I’m Professor Keith Hawton from the Centre for Suicide Research at the University of Oxford in the UK.
Katrina: And I’m Dr Katrina Witt from the Centre for Youth Mental Health at The University of Melbourne in Australia.
Keith: First of all, a bit about what we mean by self-harm and its importance. By self-harm we include all non-fatal acts of self-poisoning (such as intentional drug overdoses) or intentional self-injuries, and this is a growing problem in most countries. It is strongly associated with suicide, which is the third leading cause of death for children aged 10 to 14 years, and the second among adolescents and young adults aged 14 to 24 years. And in older adults, suicide is a leading cause of death, particularly in middle age. Whilst self-harm and suicide concerns us at all times, they become all the more concerning during times of crisis, such as financial crises, natural disasters, and of course the recent COVID-19 pandemic.
Both self-harm and suicide are the result of a complex interplay between genetic, biological, psychiatric, psychosocial, cultural, and other factors. Prevention of both self-harm and suicide requires attention to these factors. Once aspect to this is the development of effective interventions or treatments for people who present to clinical services following an episode of self-harm.
Many years ago we started reviewing the effectiveness of interventions based on trials conducted throughout the world that had been done at that time. These reviews have been updated, and our latest updates were done in 2021 to coincide with updated guidance provided by NICE in the UK which is the National Institute of Health and Care Excellence.
Katrina: To support up-to-date guidance in this respect, we have updated our Cochrane reviews of pharmacological and psychosocial interventions for self‐harm in adults and all types of interventions for self‐harm in children and adolescents. These are by far the largest versions of these reviews. The primary outcome for the reviews is repeated self-harm which is measured over a maximum time period of two years, and we also examined treatment adherence, levels of depression, hopelessness, general and social functioning, suicidal ideation, and suicide death.
The most common form of therapy in the trials that were included this update was Cognitive Behavioural Therapy (CBT)-based psychotherapy, which was investigated in 23 of the trials. Cognitive Behavioural Therapy-based psychotherapy help people to identify and critically evaluate the ways in which they interpret and evaluate disturbing emotional experiences and events. It aims to help them change the ways in which they deal with their problems. Other commonly investigated forms of psychotherapy included Dialectical Behaviour Therapy (DBT), and mentalisation-based therapy (MBT).
Only seven trials investigated the effectiveness of pharmacological, or drug, treatments, and all of these had been conducted with adults. Three tested newer generation antidepressants, and there were also individual trials that investigated the effectiveness of antipsychotics, mood stabilizers, and the latest trial tested the effects of natural products; omega-3 essential fatty acid supplementation.
Keith: Turning to our findings, and starting with the children and adolescents review, there were positive effects for a relatively prolonged form of psychological therapy, called Dialectical Behaviour Therapy for Adolescents. This usually takes place over three to six months, and it was shown to be effective in terms of preventing the numbers of times individuals repeated self-harm.
For adults, we found positive effects for psychological therapy based on CBT approaches in terms of the impact on repetition of self-harm at six and 12 months after entering therapy, and for mentalisation-based therapy (or MBT), and emotion-regulation psychotherapy shortly after the intervention was delivered. There is also some evidence of positive effects for standard dialectical behaviour therapy on frequency of self-harm repetition. However, there is no clear evidence currently for pharmacological treatments specifically for the prevention of repetition of self-harm being effective.
Katrina: It is encouraging for clinicians that there are some evidence-based psychosocial interventions that they can deliver, and it is hoped that in due course further research will help to identify other effective approaches. We also hope these findings also encourage patients and their carers to seek help. It is really important that future research focuses on what are the important outcomes for those who self-harm, their carers, and their families and that these are evaluated in future trials in this area.
Keith: Our findings are being incorporated into the forthcoming NICE or National Institute of Health and Care Excellence guidance on interventions following self-harm. While NICE is a UK-based organization, its recommendations do have influence elsewhere alongside other guidance developed in individual countries.
Katrina: If you would like to read more about these reviews and the recommendations for future research, all three reviews are available freely online at Cochrane dot com. If you simply search for “self-harm” you’ll see the list of them.