Isaac Sakinofsky

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

Clinical rating scales in suicide risk assessment.

This study explores the usefulness of clinical rating scales in the assessment of suicidal risk in an urban psychiatric teaching hospital. Admission for clinically evaluated suicide risk was the outcome variable because actual suicide occurs rarely. Six clinical scales identified high-risk patients: the Modified SAD PERSONS scale, revised Beck Depression Inventory, Beck Anxiety Inventory, Beck Hopelessness Scale, Beck Scale for Suicidal Ideation (BSS), and the High-Risk Construct Scale (NEW). It was hypothesized that patients who scored highly on the clinical scales were more likely to be admitted. Five of the scales had previously established psychometric properties, while one was new and untested. For our patient population, the established scales had 100% sensitivity and negative predictive value, but lower specificity and positive predictive value (range = 38-90% & 28-71%). We performed a correlation matrix and regression analysis to determine which scale(s) best predicted admission based upon suicidal concerns. The previously untested NEW scale was the best predictor followed by the BSS. Clinical rating scales cannot predict suicide in the individual and strict cut-off scores should not be used to dictate admission to hospital. However, the information provided can be a valuable adjunct to suicide risk assessment in psychiatric and non-psychiatric emergency settings

Preventing Suicide among Inpatients

Objective: Inpatient suicide comprises a proportionately small but clinically important fraction of suicide. This study is intended as a qualitative analysis of the comprehensive English literature, highlighting what is known and what can be done to prevent inpatient suicide. Method: A systematic search was conducted on the Cochrane Library, PubMed, Embase, Web of Knowledge, and a personal database for articles on cohort series, preferably controlled, of inpatient suicide (not deliberate self-harm or attempted suicide, unless they also dealt specifically with suicide data). Results: A qualitative discussion is presented, based on the findings of the literature searched. Conclusions: The bulk of inpatient suicides actually occur not on the ward but off premises, when the patient was on leave or had absconded. Peaks occur shortly after admission and discharge. It is possible to reduce suicide risk on the ward by having a safe environment, optimizing patient visibility, supervising patients appropriately, careful assessment, awareness of and respect for suicide risk, good teamwork and communication, and adequate clinical treatment.

Clinical model for suicide risk assessment

Abstract The assessment of an individuals risk for suicide is one of the clinicians most challenging tasks. Recent advances in both research and theory on suicide offer some guidelines to those who work with suicidal patients, including viewing risk assessment us an ongoing feature of treatment. Assessment is presented in a two-tiered model comprising background/contextual factors and subjectivity. The clinical assessment of subjectivity is formulated around Shneidmans (1985) concepts of perturbation and lethulity. The decision regarding hospital admission versus ambulatory care is also discussed. A theoretically informed approach to assessment should serve both interview and me traditional psychological assessment methods.

Suicide: The Persisting Challenge

In Canada, 4074 persons took their lives in 1999, the latest year for which suicide data are available. This equates with age-standardized death rates of 21 and 5 per 100 000 for males and females, respectively, and of 13 per 100 000 for the sexes combined. Suicide remains a grave problem in this country; it burgeoned during the late 1960s and 1970s, peaked in the early 1980s, and plateaued just below its peak during the 1990s. Although female suicide rates have decreased, suicide stubbornly remains at this level for males (who comprise four-fifths of suicides) (Figure 1). Contrast this with Scandinavian countries such as Sweden, where suicide rates decreased 28% between 1991 and 1997 in parallel with the increased use of antidepressants. In no demographic subgroup in Sweden did suicide rates fall without a corresponding increase in the use of antidepressants. Further, this decrease was not apparently related to changes in unemployment rates or alcohol misuse (1,2). The inverse relation between suicide rates and antidepressant use was also seen over this period in 3 other Nordic countries. However, suicide rates did not decrease in women under age 30 years or over age 75 years, despite increased antidepressant use. Whether the association between the expanding use of antidepressant drugs and the fall in suicide rates in some Scandinavian demographic groups is directly causal may well be debated, but as one who was a medical student before there were any antidepressants, I have no doubt that these drugs have been of overall benefit to those with mental illness.

Reply: Suicide: The Persisting Challenge

constantly reviewed the situation and immediately introduced appropriate treatment. The patient and relatives were grateful for speedy recoveries. After she had seen me writing this opinion on the chart, I recall the ward sister saying, “But Dr Sim, you are accepting the full responsibility.” I replied that that was why they paid me more. It is much easier to follow this course, for no time was wasted in debating policy with the team, whose only advantage is to ensure that nobody is to blame.

Book Review: Comprehensive Textbook of SuicidologyComprehensive Textbook of Suicidology. MarisRonald W, BermanAlan L, SilvermanMorton M, editors. New York: The Guilford Press; 2000. 650 p. USD70.00

mother. (Most such chil dren are fe male, hence the pro noun “she.”) There fore, the “re la tional ap proach” fo cuses on mak ing safe, re stor ing, and strength en ing the mother–daugh ter bond. Re search has found that pa ren tal sup port is the best pre dic tor of free dom from clini cal symp toms and is as so ci ated with the child’s main tain ing so cial com pe tence. Fol low ing this, Shein berg and Fraen kel note that the de vel op ment of per sonal agency and free dom from selfblame for abuse are goals for the child, while the non of fend ing par ent’s goals are to be a mor ally sound and pro tec tive care giver—one who can tol er ate the child’s ex pres sion of a range of feel ings about the of fender. When non of fend ing moth ers of sexuallyabused chil dren ac cess with out shame and guilt their oftenhidden yearn ings for lov ing con nec tion with their vio lent abus ing part ner, they can put their child’s safety first. The authors have found that the wellmeaning de sire of the ex tended fam ily and the com mu nity to sim plify the story of good and evil of ten re sults in sec on dary re trau ma ti za tion, be cause fam ily mem bers feel bound to hide their own ex pe r i ences . De scr ibed as the “Both–And” path, mixed feel ings that are mani fest in ap par ently mu tu ally ex clu sive per sonal at ti tudes and fam ily be liefs are ac tively ex plored, as is their link to loy alty bonds and en dur ing at tach ments.