Ellen Townsend

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

Abstract 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

Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study

Abstract Objective: To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter. Setting: UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999. subjects: People who died by suicidal or accidental overdose with paracetamol or salicylates, or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates. Main outcome measures: Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates. Results: Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change. Conclusion: Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs. What is already known on this topic Paracetamol and salicylate overdoses are very common in the United Kingdom and are associated with high levels of mortality and morbidity International comparison shows that national mortality from paracetamol overdose may be related to the maximum number of tablets in individual preparations Legislation to limit the size of packs of paracetamol and salicylates was introduced in the United Kingdom in September 1998 What this study adds The number of tablets in packets of paracetamol and salicylate preparations decreased markedly in the 12 months after the legislation The number of deaths from self poisoning with paracetamol alone and with salicylates alone decreased after the legislation There was also a decrease in the number of liver transplants and admissions to liver units with hepatic paracetamol poisoning and in the number of overdoses of paracetamol and salicylates in which large numbers of tablets were taken

The efficacy of problem­solving treatments after deliberate self­harm: meta­ analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems

BACKGROUND Brief problem-solving therapy is regarded as a pragmatic treatment for deliberate self-harm (DSH) patients. A recent meta-analysis of randomized controlled trials (RCTs) evaluating this approach indicated a trend towards reduced repetition of DSH but the pooled odds ratio was not statistically significant. We have now examined other important outcomes using this procedure, namely depression, hopelessness and improvement in problems. METHOD Six trials in which problem-solving therapy was compared with control treatment were identified from an extensive literature review of RCTs of treatments for DSH patients. Data concerning depression, hopelessness and improvement in problems were extracted. Where relevant statistical data (e.g. standard deviations) were missing these were imputed using various statistical methods. Results were pooled using meta-analytical procedures. RESULTS At follow-up, patients who were offered problem-solving therapy had significantly greater improvement in scores for depression (standardized mean difference = -0.36; 95% CI -0.61 to -0.11) and hopelessness (weighted mean difference =-3.2; 95% CI -4.0 to -2.41), and significantly more reported improvement in their problems (odds ratio = 2.31; 95% CI 1.29 to 4.13), than patients who were in the control treatment groups. CONCLUSIONS Problem-solving therapy for DSH patients appears to produce better results than control treatment with regard to improvement in depression, hopelessness and problems. It is desirable that this finding is confirmed in a large trial, which will also allow adequate testing of the impact of this treatment on repetition of DSH.

Substances used in deliberate self-poisoning 1985–1997: trends and associations with age, gender, repetition and suicide intent

Background: Rates of deliberate self-poisoning have increased in recent years. While over-the-counter availability and prescribing patterns may influence trends in substances used in overdose, these may also be related to clinical characteristics of patients. We investigate trends in substances used for self-poisoning and the influence of age, gender, suicidal intent and repetition status on the substances used. Method: Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends and patterns of self-poisoning between 1985 and 1997. Results: There were substantial increases in self-poisoning with paracetamol and antidepressants. While the increase in antidepressant self-poisoning closely paralleled local prescribing figures during 1995–97, SSRI antidepressant overdoses occurred somewhat more often than expected compared with tricyclic overdoses. Paracetamol overdoses were more common in first-timers and young people, whereas overdoses of antidepressants and tranquillizers were more common in repeaters and older people. Self-poisoning with gas and non-ingestible poisons was associated with high suicidal intent. Conclusions: There have been marked changes in the substances used for self-poisoning, which seem primarily to reflect availability, as do the influences of age and repeater status on choice of substances used. Degree of suicidal intent may also influence choice of method of self-poisoning.

Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case–controlled sample

Objective The impact of different weaning methods on food preferences and body mass index (BMI) in early childhood is not known. Here, we examine if weaning method—baby-led weaning versus traditional spoon feeding—influences food preferences and health-related outcomes. Design, setting and participants Parents (n=155) recruited through the Nottingham Toddler laboratory and relevant internet sites completed a questionnaire concerning (1) infant feeding and weaning style (baby-led=92, spoon-fed=63, age range 20–78 months), (2) their childs preference for 151 foods (analysed by common food categories, eg, carbohydrates, proteins, dairy) and (3) exposure (frequency of consumption). Food preference and exposure data were analysed using a case–controlled matched sample to account for the effect of age on food preference. All other analyses were conducted with the whole sample. Main outcome measures The primary outcome measures were food preferences, exposure and weaning style. The secondary outcome measures were BMI and picky eating. Results Compared to the spoon-fed group, the baby-led group demonstrated (1) significantly increased liking for carbohydrates (no other differences in preference were found) and (2) carbohydrates to be their most preferred foods (compared to sweet foods for the spoon-fed group). Preference and exposure ratings were not influenced by socially desirable responding or socioeconomic status, although an increased liking for vegetables was associated with higher social class. There was an increased incidence of (1) underweight in the baby-led group and (2) obesity in the spoon-fed group. No difference in picky eating was found between the two weaning groups. Conclusions Weaning style impacts on food preferences and health in early childhood. Our results suggest that infants weaned through the baby-led approach learn to regulate their food intake in a manner, which leads to a lower BMI and a preference for healthy foods like carbohydrates. This has implications for combating the well-documented rise of obesity in contemporary societies.

Deliberate Self-Harm Patients with Alcohol Disorders: Characteristics, Treatment, and Outcome

Deliberate self-harm (DSH) patients with alcohol problems present a considerable challenge for clinical services. In a study of a sample of 150 DSH patients who were representative of all such patients seen at a general hospital during the study period, 40 patients with an ICD-10 diagnosis of alcohol dependence or harmful use of alcohol were compared with the remainder of the sample. The treatment of the patients with alcohol disorders before and after the episode of DSH and the outcome 12-20 months later were also investigated. Compared with other DSH patients, those with an alcohol diagnosis were older and more often male, living alone, unemployed, sick, disabled, or with a past history of DSH. They also had higher scores on measures of anger, aggression, and impulsivity. Comorbid psychiatric disorder was present in 37 (92.5%) patients, this being depression in three-quarters of those cases. Fourteen (35.0%) patients were receiving treatment from the psychiatric services prior to DSH, and 33 (82.5%) were subsequently offered treatment. Of the patients who were followed up, 37.9% remained in contact with psychiatric services, 55.2% showed poor compliance with treatment and 44.8% reported a further episode of DSH. All patients presenting after DSH need to be carefully screened for alcohol disorders and for comorbid psychiatric diagnoses. Treatment of DSH patients with alcohol disorders should include the treatment of any comorbid depressive illness.

Systematic review and meta-analysis of interventions relevant for young offenders with mood disorders, anxiety disorders, or self-harm

Background Mood and anxiety disorders, and problems with self-harm are significant and serious issues that are common in young people in the Criminal Justice System. Aims To examine whether interventions relevant to young offenders with mood or anxiety disorders, or problems with self-harm are effective. Method Systematic review and meta-analysis of data from randomised controlled trials relevant to young offenders experiencing these problems. Results An exhaustive search of the worldwide literature (published and unpublished) yielded 10 studies suitable for inclusion in this review. Meta-analysis of data from three studies (with a total population of 171 individuals) revealed that group-based Cognitive Behaviour Therapy (CBT) may help to reduce symptoms of depression in young offenders. Conclusions These preliminary findings suggest that group-based CBT may be useful for young offenders with such mental health problems, but larger high quality RCTs are now needed to bolster the evidence-base.

Implicit attitudes towards genetically modified (GM) foods: A comparison of context-free and context-dependent evaluations

Past research on attitudes towards GM food has focused on measuring explicit attitudes. Here we compared implicit attitudes towards GM foods with explicit attitudes towards GM foods. We used the Go No-Go task to investigate context-free implicit evaluations of GM foods and compared these with evaluations made in the context of ordinary and organic foods. Semantic differential scales were used to evaluate explicit attitudes towards GM foods. As expected, explicit attitudes towards GM foods were found to be neutral. However, contrary to our hypotheses, participants were found to hold positive, rather than neutral, implicit attitudes towards GM foods when these were assessed in a context free manner. In addition, neutral implicit attitudes were found when attitudes were assessed in the context of ordinary or organic foods, again contrasting with our hypotheses. These results imply that implicit attitudes towards GM food are more positive than anticipated and may lead to approach behaviour towards such products. Thus, given the choice, consumers are likely to accept GM food although other incentives may be needed if alternative foods are available.

Affective Influences on Risk Perceptions of, and Attitudes Toward, Genetically Modified Food

Much has been written about risk perceptions and public understanding of genetically modified (GM) food, yet little if any of the academic writings on this topic take into account the role of feelings or affect in these processes. Here, the available literature on the topic of GM food is explored in order to highlight findings consistent with the notion that feelings about GM food are important in shaping judgements about it. Using evidence emerging from the burgeoning literature in the domain of risk and feelings, an exploration of the role of affect is shown to be an important direction for future research on the perceived risks associated with GM food. The potential effects of incidental and integral affect are considered, and the importance of using rigorous social science methods is stressed. To increase understanding of the role of feelings in making judgements and decisions about GM food, future studies should consider measuring integral and incidental affect in addition to other key factors such as the vividness of imagery associated with GM, knowledge, perceived need, perceived benefits and trust.

Family history of suicidal behaviour: prevalence and significance in deliberate self-harm patients.

Objective:  To investigate whether there are differences between the characteristics of deliberate self‐harm (DSH) patients with and without a family history of suicidal behaviour.