Self-harm (such as cutting or burning) is one of the known predictors of suicide risk. The medical community has long been interested in potential psychological interventions that could target this behavior as a way of preventing future self-harm and/or suicide. A new study just published in The Lancet Psychiatry examines one such intervention: a brief worksheet for self-harm prevention. Unfortunately, the researchers found that their worksheet was ineffective at preventing future re-hospitalizations.
There is some evidence that psychological interventions can reduce self-harm or suicidal behaviors. Most of this evidence centers around longer-term psychological interventions such as dialectical behavior therapy (DBT), and cognitive-behavior therapy (CBT). However, even this evidence has been rated as “low quality” in a recent (2016) meta-analysis by the well-regarded Cochrane Group. Other interventions did not merit even this distinction, instead, they were rated as “inconclusive.”
The authors of the current study attempted to improve this inconclusive research by using a large randomized, controlled trial design to study the effectiveness of their brief worksheet-based intervention. The researchers studied 518 patients, randomly assigned to either a brief psychological intervention or to a control group that received treatment as usual (no additional treatment). All patients had been admitted to a single hospital in the UK after a suicide attempt.
The researchers termed their worksheet a “volitional help sheet (VHS).” It contained a number of “if… then…” statements which the researchers believed could enable participants to identify alternative coping strategies when feeling the urge to self-harm or attempt suicide.
The researchers measured three primary outcomes: 1) the percentage of participants who were hospitalized again for self-harm; 2) the number of times individual participants were re-hospitalized for self-harm; and 3) the estimated cost-effectiveness of the worksheet.
The results were striking: there was no difference in the percentage of participants re-hospitalized, nor was there a difference in the number of times individuals were re-hospitalized. That is, the researchers determined that their intervention was completely ineffective for preventing self-harm.
After the failure of their primary outcomes, the researchers conducted secondary analyses to determine if their intervention might be helpful for any subgroup. In this posthoc analysis, the researchers found that people who had previously been admitted to hospitals for self-harm behaviors appeared slightly more likely to improve after the VHS intervention. The researchers state that because this was not part of their original study design, the finding needs to be replicated in future studies before it can inform policy or treatment decisions.
According to the authors: “For those with no history of self-harm hospital admission, the VHS might increase self-harm (i.e., do harm).”
The study was also limited in that it only examined re-hospitalizations. Most self-harm behaviors do not result in hospitalization, which means that it is likely that a large number of participants continued self-harming and simply were not identified during the follow-up period of the study.
In a commentary on the study also published in The Lancet Psychiatry, Katrina Witt writes that researchers hope to find “brief psychological interventions that require minimal expertise to deliver” since many people who admit to hospitals with self-harm and suicidality will not go on to receive mental health services. However, Witt also questions whether brief interventions will do more harm than good:
“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.”
As it stands now, these interventions may do more harm than good. According to the researchers, further study is needed to determine the efficacy of any of these interventions for reducing self-harm and suicidal behavior.
O’Connor, R., Ferguson, E., Scott, F., Smyth, R., McDaid, D., Park, A. . . . Armitage, C. J. (2017). A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: a randomised controlled trial. The Lancet, 4(6), 451-460. (Link)
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.