BMJ 1998;317:441-447 ( 15 August )

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Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition

Keith Hawton, professor of psychiatry, a Ella Arensman, postdoctoral research psychologist, a Ellen Townsend, postdoctoral research psychologist, a Sandy Bremner, consultant psychiatrist, b Eleanor Feldman, consultant liaison psychiatrist, c Robert Goldney, professor of psychiatry, d David Gunnell, senior lecturer in epidemiology and public health, e Philip Hazell, professor of psychiatry, f Kees van Heeringen, professor of psychiatry, g Allan House, senior lecturer in psychiatry, h David Owens, senior lecturer in psychiatry, h Isaac Sakinofsky, professor of psychiatry, i Lil Träskman-Bendz, professor of psychiatry. j

a Department of Psychiatry, Oxford University, Warneford Hospital, Oxford OX3 7JX, b Psychological Medicine, Nepean Hospital, PO Box 63, Penrith, NSW 2750, Australia, c Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, d Department of Psychiatry, University of Adelaide, Adelaide, SA 5005, Australia, e Department of Social Medicine, University of Bristol, Bristol BS8 2PR, f Discipline of Psychiatry, Faculty of Medicine and Health Sciences, University of Newcastle, Callaghan, NSW 2308, Australia, g Department of Psychiatry, University Hospital, 9000 Ghent, Belgium, h Division of Psychiatry and Behavioural Sciences, School of Medicine, University of Leeds, Leeds LS2 9LT, i Clarke Institute of Psychiatry, Toronto, Canada MST IR8, j Department of Psychiatry, University Hospital, 221 85 Lund, Sweden

Correspondence to: Professor Hawton Keith.Hawton{at}psychiatry.ox.ac.uk

Objective: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves.
Design: Systematic review of randomised controlled trials of psychosocial and physical treatments. Studies categorised according to type of treatment. When there was more than one investigation in a particular category a summary odds ratio was estimated with the Mantel-Haenszel method.
Setting: Randomised trials available in electronic databases in 1996, in the Cochrane Controlled Trials Register in 1997, and from hand searching of journals to 1997. 
Subjects: Patients who had deliberately harmed themselves shortly before entry into the trials with information on repetition of behaviour. The included trials comprised 2452 randomised participants with outcome data.
Main outcome measure: Repetition of self harm.
Results: 20 trials reported repetition of self harm as an outcome variable, classified into 10 categories. Summary odds ratio (all for comparison with standard aftercare) indicated reduced repetition for problem solving therapy (0.73; 95% confidence interval 0.45 to 1.18) and for provision of an emergency contact card in addition to standard care (0.45; 0.19 to 1.07). The summary odds ratios were 0.83 (0.61 to 1.14) for trials of intensive aftercare plus outreach and 1.19 (0.53 to 2.67) for antidepressant treatment compared with placebo. Significantly reduced rates of further self harm were observed for depot flupenthixol versus placebo in multiple repeaters (0.09; 0.02 to 0.50) and for dialectical behaviour therapy versus standard aftercare (0.24; 0.06 to 0.93).
Conclusion: There remains considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective. Further larger trials of treatments are needed.

Key messages

  • A systematic review of the effectiveness of psychosocial and drug treatments of patients who deliberately harm themselves identified 20 randomised controlled trials in which repetition of self harm was reported as an outcome

  • Promising results were found for problem solving therapy, provision of a card to allow patients to make emergency contact with services, depot flupenthixol for recurrent self harm, and long term psychological therapy for female patients with borderline personality disorder and recurrent self harm

  • Assertive outreach can help to keep patients in treatment

  • Nearly all the trials included too few patients to detect clinically significant differences in repetition of self harm, and even synthesis of results by meta-analysis did not have the power to detect such differences

  • There is an urgent need for large trials of promising therapies for this substantial clinical population



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