ATLANTA (FRONTLINE MEDICAL NEWS)The strongest evidence to date that brief psychological therapy is effective in reducing repetition of acts of self-harm comes from a new Cochrane Collaboration meta-analysis.

Current guidelines on management of self-harm provided by the United Kingdom’s National Institute for Health and Care Excellence (NICE) state that psychological therapy “may” prevent recurrent self-harm, but this guidance relied upon limited evidence. The new Cochrane Collaboration review, based on 18 randomized controlled trials, greatly strengthens support for that conclusion, Dr. Keith Hawton said at the annual meeting of the American Association of Suicidology.

“And I’ve got to add, of course, that psychological therapy may be at least as effective in terms of other important outcomes,” observed Dr. Hawton, lead author of the soon-to-be published Cochrane meta-analysis. Dr. Hawton is professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

The meta-analysis included 11 randomized trials of brief psychological therapy or treatment as usual in adults in which the primary outcome was repetition of self-harm during 6 months of follow-up. There were 146 such events in 663 patients who underwent psychological therapy, compared with 176 events in 640 controls, for an adjusted 43% relative risk reduction.

In 10 trials featuring 12 months of follow-up, some of which were also included in the 6-month analysis, there were 263 events in 1,101 psychotherapy recipients, compared with 308 events in 1,131 controls. That translates into a statistically significant 20% relative risk reduction favoring brief psychotherapy.

Depression scores at last follow-up were significantly lower in the psychotherapy recipients, compared with treatment as usual. So were hopelessness and suicidal ideation scores.

Nine suicides occurred among 1,169 patients randomized to psychotherapy, vs. 15 in 1,185 controls. Although this represents a 34% relative risk reduction, the difference wasn’t significant, because suicide was such a rare event, even in these high-risk patients who – as documented in the Multicentre Study of Self Harm in England – have a 50-fold greater risk of death by suicide in the year following a self-harm event than the risk in the general population.

“This illustrates the problem in using suicide as an outcome, even when you stack up a lot of studies,” Dr. Hawton noted.

The trials in the meta-analysis were conducted throughout the world, so “treatment as usual” in the control arm varied from study to study. But even in the United Kingdom, where the NICE guidelines state that all self-harm patients who present to a hospital should receive a psychosocial assessment, including an evaluation of their needs and risks, a 32-hospital study showed that only 60% of self-harm patients actually get such an assessment, the psychiatrist said.

A variety of forms of brief psychological therapy for self-harm were employed in the randomized trials. Most involved short-term cognitive-behavioral therapy, problem-solving therapy, or dialectical behavior therapy. Components shared by the various regimens included engagement; a careful examination of the process associated with an individual’s self-harm; problem-solving; cognitive therapy to address the patient’s problems, thoughts, images, and core beliefs; and ongoing monitoring of depression, hopelessness, and thoughts of self-harm.

“The self-harm population is very heterogeneous. There’s a wide range of problems and needs. Brief psychological therapy isn’t suitable for all patients. We’ve estimated that about 30% could benefit from this approach,” according to Dr. Hawton.

Based in part upon the Cochrane Collaboration analysis, the local directors of health services across England and Wales recently have received guidance that brief psychological therapy is to be made available routinely to patients seen by self-harm mental health programs, he added.

Self-harm is defined in the United Kingdom as intentional nonfatal self-poisoning or self-injury regardless of the degree of suicidal intent.

Looking ahead, Dr. Hawton cited several developments that show promise as potential new therapies for self-harm patients.

“Mindfulness has achieved great success in recent years, particularly based on very impressive impacts in people with relapsing depression. This is clearly an area that’s going to be developed in relation to the self- harm population. In fact, there is already work going on,” he said.

Similarly, randomized studies are underway evaluating ketamine and its analogs for acute suicidality based upon the highly favorable results reported in treating severe depression.

Internet and mobile telephone–based interventions for self-harm patients are “proliferating” at the moment, Dr. Hawton said.

“One of the issues is how to individualize therapy through these approaches,” he noted.

Dr. Hawton’s research is funded by the National Institute for Health Research. He reported having no financial conflicts.


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