Introduction

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Prevention of suicide is now included in health policy initiatives in several countries, and reduction in suicidal behaviour, both fatal and non-fatal, is part of the Health for All targets of the World Health Organisation.¹ In the United Kingdom, reduction in the number of suicides is a central theme in the government's Health of the Nation strategy for England.² There is, however, a considerable lack of information as to which preventive strategies are effective.³ Improvement of outcome after deliberate self harm is an important focus because at least 1% of patients presenting to general hospitals in the United Kingdom after deliberate self harm kill themselves within a year and 3-5% do so within 5-10 years. A history of multiple episodes of deliberate self harm is a particular risk factor.⁴ Higher rates of suicide after deliberate self harm have been reported from other countries. ^{5 6} About half of all people who kill themselves have a history of deliberate self harm, an episode having occurred within the year before death in 20-25%. ^{7 8}

It would be difficult to investigate the effectiveness of intervention strategies after deliberate self harm in terms of subsequent actual suicides because extremely large populations of patients would be required. Repetition of deliberate self harm is, however, a reasonable proxy measure because of its strong associations with suicide. It is also in itself an important outcome because it occurs frequently, ^{9 10} indicates persistent distress, and results in considerable healthcare costs. Deliberate self harm is common in Europe¹¹ and in other parts of the world, ^{12 13} especially in young people. Recent marked increases in rates of deliberate self harm in the United Kingdom, ^{14 15} with a currently estimated 140 000 hospital referrals in England and Wales,¹⁰ have highlighted the need for effective aftercare strategies.

Descriptive reviews of treatment outcomes in patients who deliberately harm themselves have been published previously but have not included systematic screening of the literature, quality ratings, and meta-analysis,^16-18 and have been based on heterogeneous groupings of treatments which do not inform clinical practice.¹⁹

We conducted a systematic review of the worldwide literature regarding treatment studies of patients who deliberately harm themselves. We identified all randomised controlled trials evaluating psychosocial or physical treatments and conducted a meta-analysis to compare the effects of specific treatments on repetition of deliberate self harm with those of control or comparison treatments to identify the most effective interventions.

	Methods

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Inclusion criteria We included studies in the review if they met the following criteria: study participants had to have engaged in deliberate self harm (self poisoning or self injury) shortly before entry into the trial; trials must have reported repetition of deliberate self harm as an outcome measure; and study participants had to have been randomised to treatment and control groups. As long as these three criteria were met we included papers reporting any comparison between different types of treatment, including comparisons with standard (that is, routine) aftercare. When details of standard aftercare were not provided, we attempted to obtain these from the authors.

Grouping of studies Studies that shared similar treatment strategies were grouped by consensus of the reviewers, blind to the outcome data. The first category (problem solving therapy v standard aftercare) included studies in which participants in the experimental group were offered some form of problem solving therapy which was compared with standard aftercare. Standard aftercare, both here and in other categories, included the usual range of treatment options that were available in routine care at the time in each setting. The second group (intensive intervention plus outreach v standard aftercare) included studies in which the patients in the experimental group had greater access to therapists than in standard care and where efforts were made to keep contact with patients through some form of outreach (for example, home based treatment either as standard or for those patients who defaulted on appointments at a clinic). The third group (emergency card v standard aftercare) included studies in which patients in the experimental group, in addition to being offered standard aftercare, were given an emergency contact card with which they had 24 hour access to emergency advice from a psychiatrist²¹ or could admit themselves to hospital.²² In only one other group (antidepressant medication v placebo) was there more than one trial. The remainder of the studies are reported singly.

Data extraction and quality assessment Data were extracted independently by two reviewers. The quality of the papers was rated by two independent reviewers blind to authorship, according to the recommended Cochrane criteria for quality assessment.²³ This rating system is influenced by the finding that the quality of concealment of random allocation can affect the results of trials.²⁴ Studies were assigned a quality score from 1 (poorest quality) to 3 (best quality). Thus, trials rated as inadequately concealed (for example, via alternation or reference to an open random number table) were given a score of 1. Trials that did not give adequate details about how the randomisation procedure was carried out were given a score of 2. Trials that were deemed to have taken adequate measures to conceal allocation (for example, serially numbered, opaque, sealed envelopes; numbered or coded bottles or containers) were given a score of 3. We contacted authors of trials for more information when the concealment of allocation was not clearly reported (that is, when trials were initially in category 2). Blinding of observers was rated according to whether it was absent or unclear, reported but without details, and fully reported.

Statistical methods Summary odds ratios were calculated with RevMan 3.0 software²⁵ with the Mantel-Haenszel method. Heterogeneity was tested with a ² test.

	Results

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Twenty studies were identified through the combined search strategies as eligible for inclusion in the study. All reports had been published, although two studies had not been published in full. ^{16 26} The full report of one trial was provided by the author in the form of an unpublished manuscript,¹⁶ and a detailed report of the other was obtained from conference proceedings.²⁶ Four studies had been reported in more than one publication. ^{16 26-28} One further randomised controlled trial of patients who deliberately harmed themselves was identified, but this did not include repetition of deliberate self harm as an outcome variable.²⁹ We were unable to obtain this information from the authors of this trial.

The trials identified were grouped as described in the methods section. Table 1 summarises the 20 trials included in the review, their groupings, details of participants (sex and the proportion with a history of self harm"repeaters"), the interventions used, and the quality of concealment scores. Only one trial was specifically of adolescents.²²

The assessment of quality of concealment of allocation (table 1) resulted in 13 trials being given a score of 3 (for adequate concealment), three trials being given a score of 2 (unclear concealment), and four trials being given a score of 1 (inadequate concealment). Blinding of assessors was not stated or was unclear in 12 trials, was indicated but no further details given in seven trials, and was fully reported in one trial.

A total of 2641 patients were randomised in the 20 trials, and outcome data regarding repetition of deliberate self harm during follow up were available for 2452. The results of the individual studies in terms of repetition of deliberate self harm during follow up are shown in table 2. Also shown is the number of suicides, when these were reported.

Summary odds ratios
The summary odds ratios for each of the treatment categories that included more than one study are shown in the figure, which also indicates the total number of patients within each category.

View larger version (41K): [in this window] [in a new window]   Summary odds ratios for repetition of deliberate self harm during follow up in treatment categories for which there was more than one trial

Intensive intervention plus outreach versus standard aftercare There was no consistent direction of effect among studies in this group (see figure). Inclusion of only those trials with the highest quality of concealment of allocation did not greatly alter the summary odds ratio (0.86; 0.60 to 1.23).

Emergency card versus standard aftercare In both studies in this comparison there was a tendency towards less repetition of self harm in the experimental group, but the summary odds ratio 0.45 (0.19 to 1.07) was not significant. The odds ratio was similar when only the results of the trial with the highest quality rating were analysed (0.43; 0.15 to 1.27).

Dialectical behaviour therapy versus standard aftercare In this study²⁷ there was a significantly lower rate of repetition of self harm during follow up in patients who received dialectical behaviour therapy (see table 2; 0.24; 0.06 to 0.93; number needed to treat=3). This comparison, however, was restricted to a subgroup of randomly assigned patients which was smaller than that which entered the original trial.⁴⁶

Inpatient behaviour therapy versus inpatient insight orientated therapy The small sample size of the single study in this comparison (see table 2) precluded meaningful conclusions from the odds ratio analysis (0.60; 0.08 to 4.45).

Same therapist versus different therapist The repetition rate in the group of patients who received aftercare from the same person who assessed them in hospital after their initial episode of deliberate self harm was significantly higher than that of patients who had a change of clinician (see table 2; 3.70; 1.13 to 12.09). The authors reported, however, that despite randomisation there were several imbalances between the experimental and control groups, resulting in a greater prevalence of risk factors for repetition in the experimental group. It is of note that continuity of therapist resulted in 48/68 (71%) patients attending at least one outpatient treatment session compared with 34/73 (47%) patients in the control group (2.75; 1.37 to 5.52).

General hospital admission versus discharge The odds ratio from the one study in this category (see table 2) did not indicate a beneficial effect of general hospital admission after deliberate self harm (0.75; 0.16 to 3.60). Only 15% of patients referred, however, were eligible for inclusion in the study as only those attempters at low risk and without immediate medical or psychiatric needs could be considered for discharge without treatment. The follow up period was relatively short.

Flupenthixol versus placebo There was a significant reduction in repetition of deliberate self harm in patients receiving flupenthixol (see table 2; 0.09; 0.02 to 0.50; number needed to treat=2). The trial was relatively small and all the patients were repeaters.

Antidepressants versus placebo The summary odds ratio for the two studies in this category (see figure) indicated no apparent benefit regarding repetition of deliberate self harm for patients treated with mianserin or nomifensine compared with placebo (1.19; 0.53 to 2.67).

Long term therapy versus short term therapy There was no indication that long term therapy was more effective in terms of preventing repetition than short term therapy for patients with a history of self harm (see table 2; 1.0; 0.35 to 2.86).

	Discussion

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The results of this systematic review indicate that currently there is insufficient evidence on which to make firm recommendations about the most effective forms of treatment for patients who have recently deliberately harmed themselves. This is a serious situation given the size of the problem of deliberate self harm throughout the world^10-13 and the importance of dealing with the problem to prevent suicide.³

In nearly all trials the subjects were recruited after attendance at a general hospital because of deliberate self harm. Some trials included only patients who had poisoned themselves, who constitute most of the patients who deliberately harm themselves¹⁰; others included patients who had poisoned themselves and those who had injured themselves, whereas some did not specify the method of self harm. Most of the studies focused on patients who could be treated as outpatients. Patients who, for example, required psychiatric hospital inpatient care because of severe mental illness or serious risk of suicide, or both, were excluded, but these comprise the minority of patients who harm themselves and who present to general hospitals.¹⁰ The studies examined are therefore of relevance to a large proportion of patients who deliberately harm themselves who will be treated in the community. Most patients in the studies had a history of episodes of self harm, and in seven trials the whole sample consisted of such patients. ^{26 27 32 36 42 44} Only one study included only patients with no history of self harm.²¹ In view of the considerable problem of deliberate self harm in adolescents in many countries ^{11 47} it is surprising that only one trial focused on this specific clinical population.²²

Shortcomings of trials
The comparison intervention for most of the studies of psychosocial intervention was standard care. In some studies details of this care were not provided, particularly in terms of treatment content. Future studies in which standard care is included should define precisely the nature of the treatment patients received. The dependent variable studied in this reviewnamely, repetition of self harmwas not consistently defined and measured in a standard way across all studies. In most studies repetition was based on hospital referral for further deliberate self harm, whereas in some studies interviews with patients and other informants also identified episodes of self harm which did not result in hospital referral.

Further research indicated
Promising results were found for problem solving therapy, which is a brief and reasonably easily taught form of treatment.⁵⁰ Although a clinically insignificant difference was found in the biggest trial,³⁰ a larger trial of this treatment is indicated. There were also trends favouring provision of an emergency access card in addition to standard aftercare but again a larger trial is required, including specific attention to what part the card might play as only a small minority of patients actually used the facility provided by possession of the card. ^{21 22}

Conclusion
At present, evidence is lacking to indicate the most effective forms of treatment for patients who deliberately harm themselves. This is a serious situation given the size of the population at risk and the risks of subsequent self harm, including suicide. Large trials are required of the interventions shown in small trials to be of possible benefit. There is also a need for development of further treatment approaches informed by current knowledge about the psychosocial and biological characteristics of these patients and the socioeconomic and sociocultural context of the behaviour.