Research

Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation

BMJ 2011; 342 doi: 10.1136/bmj.d682 (Published 1 April 2011)
Cite this as: BMJ 2011;342:d682
  1. J M Green, professor of child psychiatry 16,
  2. A J Wood, consultant adolescent psychiatrist2,
  3. M J Kerfoot, honorary professor of mental health studies1,
  4. G Trainor, nurse consultant3,
  5. C Roberts, reader in biostatistics1,
  6. J Rothwell, research associate1,
  7. A Woodham, research assistant1,
  8. E Ayodeji, lecturer in child and adolescent mental health4,
  9. B Barrett, lecturer in health economics5,
  10. S Byford, reader in health economics5,
  11. R Harrington, professor of child psychiatry (deceased)1
  1. 1Psychiatry Research Group, University of Manchester, Manchester M13 9PL, UK
  2. 2Tier 4 Child and Adolescent Mental Health Services, Young People’s Centre, Chester, UK
  3. 3Greater Manchester West Mental Health NHS Foundation Trust, Manchester
  4. 4School of Nursing and Midwifery, University of Salford, Salford
  5. 5Centre for the Economics of Mental Health Institute of Psychiatry, King’s College London, London, UK
  6. 6Manchester Biomedical Research Centre and Academic Health Sciences Centre, Manchester
  1. Correspondence to: Jonathan Green jonathan.green{at}manchester.ac.uk
  • Accepted 18 December 2010

Abstract

Objective To examine the effectiveness and cost-effectiveness of group therapy for self harm in young people.

Design Two arm, single (assessor) blinded parallel randomised allocation trial of a group therapy intervention in addition to routine care, compared with routine care alone. Randomisation was by minimisation controlling for baseline frequency of self harm, presence of conduct disorder, depressive disorder, and severity of psychosocial stress.

Participants Adolescents aged 12-17 years with at least two past episodes of self harm within the previous 12 months. Exclusion criteria were: not speaking English, low weight anorexia nervosa, acute psychosis, substantial learning difficulties (defined by need for specialist school), current containment in secure care.

Setting Eight child and adolescent mental health services in the northwest UK.

Interventions Manual based developmental group therapy programme specifically designed for adolescents who harm themselves, with an acute phase over six weekly sessions followed by a booster phase of weekly groups as long as needed. Details of routine care were gathered from participating centres.

Main outcome measures Primary outcome was frequency of subsequent repeated episodes of self harm. Secondary outcomes were severity of subsequent self harm, mood disorder, suicidal ideation, and global functioning. Total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses, were recorded.

Results 183 adolescents were allocated to each arm (total n=366). Loss to follow-up was low (<4%). On all outcomes the trial cohort as a whole showed significant improvement from baseline to follow-up. On the primary outcome of frequency of self harm, proportional odds ratio of group therapy versus routine care adjusting for relevant baseline variables was 0.99 (95% confidence interval 0.68 to 1.44, P=0.95) at 6 months and 0.88 (0.59 to 1.33, P=0.52) at 1 year. For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to1.20, P=0.29) at 6 months and 0.94 (0.63 to 1.40, P=0.75) at 1 year. Total 1 year costs were higher in the group therapy arm (£21 781) than for routine care (£15 372) but the difference was not significant (95% CI −1416 to 10782, P=0.132).

Conclusions The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations.

Trial registration ISRCTN 20496110

Footnotes

  • We thank all the participating teams that contributed to referrals and interventions. We particularly acknowledge the involvement of the young people and their families at a difficult time in their lives. Professor Dick Harrington inspired and led this study before his untimely death in 2004. We are grateful for the support of the Trial Steering Committee (Simon Gowers (chair), Sally Hollis, Andy Clarke, Ian McKinnon).

  • Contributors: RH, AJW, MK, GT, SB, and CR initially conceived and designed the study. JR, EA, AW, BB, and JG contributed to the design and analysis plan. AW and GT led the therapy delivery and supervision. JG led the trial following the death of Richard Harrington and the retirement of Mike Kerfoot. CR prepared the statistical analysis plan and undertook the statistical analysis. All authors contributed to the interpretation of the data. JG led the drafting of the article. All authors contributed to the revision of the article and gave final approval of the manuscript. JJG is the guarantor of the study and made the final decision to submit. All authors had full access to all of the data (including statistical reports and tables) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: The study was funded by the Health Foundation and sponsored by the University of Manchester. Neither funder nor sponsor had any role in the design, data collection, interpretation, or write up of the study. All researchers in the study were independent of the funding body.

  • Competing interest statement: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  •  Data sharing: Technical appendix, statistical code, and dataset available from the corresponding author at jonathan.green{at}manchester.ac.uk. Participant consent was not obtained but the presented data are anonymised and risk of identification is low.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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