Individuals who inflict harm upon themselves may be more likely to attempt, and to die from, suicide. Long-term psychological interventions to reduce self-harm among psychiatric outpatients have shown some promise, but brief, acute interventions are needed.
Researchers in the UK evaluated the effects of a brief psychological intervention to prevent repeat self-harm among inpatients admitted to a psychiatric facility following a suicide attempt. The results of their study were published in the Lancet Psychiatry. The intervention, based on behavior change theory, took the form of a volitional help sheet (VHS) that encouraged patients to formulate “if-then” plans to prevent self-harm. In these plans, “if” refers to a situation in which self-harm may occur (e.g., if I feel the urge to self-harm), while “then” refers to an appropriate action that the person will take to prevent self-harm from occurring (e.g., then I will call my psychologist).
The researchers conducted a 6-month randomized controlled trial at a single hospital in Edinburgh, UK. Patients aged 16 and over who were admitted to a specialist unit after attempting self-harm and who had at least one previously reported self-harm attempt were eligible to participate. Of 1308 patients assessed for eligibility, 518 were eligible and randomized to one of two groups: the VHS treatment group plus standard care, or the control group, which received standard care only. Equal numbers of patients were allocated to each group.
Clinical staff and staff who extracted medical data from patients’ charts were blinded as to the patients’ group assignment to prevent study bias. Researchers instructed patients to complete the VHS at their bedsides or in private rooms nearby. The sheet contained examples of potential situations patients might encounter and potential actions that they could take to prevent these situations; they were instructed to select situations that might apply to them, and then to match the situations with solutions. Patients kept the top copy of the VHS, while researchers collected a carbon copy attached to the top sheet to see whether patients completed their plans. Patients were not contacted again, although the treatment group received a booster in the form of a new VHS sheet mailed to their homes 2 months after they enrolled in the study.
Over the next 6 months, the researchers collected hospital data and data from medical charts to determine the number of patients who presented with repeat incidents of self-harm, the number of times each patient re-presented, and the time (i.e., number of days) that lapsed before re-presentation occurred. They also calculated the mean hospital cost per self-harm event based on typical costs associated with hospital stays for the intervention versus the control group. Sociodemographic data such as age, marital status, and past history of self-harm were also collected.
When the researchers compared the treatment and control groups, there was no difference in the numbers of patients in each group who re-presented with self-harm in the subsequent 6 months. Similarly, there were no differences in the number of re-presentations per patient, the time in days before re-presentations occurred, or the mean cost for hospital services based on group. Despite these findings, additional analyses suggested that the intervention might be beneficial to those with a history of hospitalization for self-harm. Regardless of group assignment, patients with a history were more likely to experience repeat episodes of self-harm. When group assignment was accounted for, those with a history of self-harm who did not receive the VHS treatment were more likely to re-present to the emergency department with self-harm. In contrast, those with a previous history who received the intervention had a nearly 70% reduction in the number of repeat visits to the emergency department and a 55% reduction in hospital readmissions.
Overall, the findings suggest that psychological interventions should be tailored based on patients’ needs and characteristics. Patients with a history of self-harm may benefit more from brief acute interventions like the VHS. Additional research is needed to replicate these findings, however, as many of the analyses were unplanned and exploratory in nature. The researchers were unable to assess the effects of the booster treatment administered at 2 months or patients’ feelings regarding the treatment. Future research is also needed to investigate potential detrimental effects of inventions like the VHS on patients with no history of self-harm.
Written By: Suzanne M. Robertson, Ph.D