Michael Kerfoot

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

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

Risk factors for suicide in Hungary: a case-control study

BackgroundHungary previously had one of the highest suicide rates in the world, but experienced major social and economic changes from 1990 onwards. We aimed to investigate the antecedents of suicide in Hungary. We hypothesised that suicide in Hungary would be associated with both risk factors for suicide as identified in Western studies, and experiences related to social and economic restructuring.MethodsWe carried out a controlled psychological autopsy study. Informants for 194 cases (suicide deaths in Budapest and Pest County 2002–2004) and 194 controls were interviewed by clinicians using a detailed schedule.ResultsMany of the demographic and clinical risk factors associated with suicide in other settings were also associated with suicide in Hungary; for example, being unmarried or having no current relationship, lack of other social contacts, low educational attainment, history of self-harm, current diagnosis of affective disorder (including bipolar disorder) or personality disorder, and experiencing a recent major adverse life event. A number of variables reflecting experiences since economic restructuring were also associated with suicide; for example, unemployment, concern over work propects, changes in living standards, practising religion. Just 20% of cases with evidence of depression at the time of death had received antidepressants.ConclusionSuicide rates in Hungary are falling. Our study identified a number of risk factors related to individual-level demographic and clinical characteristics, and possibly recent societal change. Improved management of psychiatric disorder and self-harm may result in further reductions in suicide rates.

A step too far? Randomized trial of cognitive-behaviour therapy delivered by social workers to depressed adolescents.

Abstract.Objective:To test the hypothesis that depressed adolescents given brief cognitive behaviour therapy by trained social workers will be less depressed after this treatment than depressed adolescents who have routine care from their social workers.Method:Open study, two randomized parallel groups. 86 social workers were randomized to training in brief CBT or delayed training by remote telephone randomization. 25 social workers who attended CBT training recruited 29 depressed adolescents. 22 social workers in the control group recruited 23 depressed adolescents.Results:Social workers’ perceptions of their knowledge and skills in dealing with adolescent depression were better after the training than before. However, in intention to treat analyses, adolescents who had therapy from trained social workers had a similar level of depression post treatment (mean depression score 17.5, 95% CI 11.8 to 23.3) to those who did not have such therapy (mean depression score 16.7, 95 % CI 11.3 to 22.1). There were no significant differences between the groups on other outcomes or at follow-up.Conclusions:This study failed to recruit enough cases and probably did not therefore have enough statistical power to detect an effect of the intervention. It was also based on a severely impaired sample with many comorbid problems. However, the results suggest that training community-based social workers in cognitive behaviour therapy is neither practical nor effective in improving the outcomes of their clients.

Developing needs led child and adolescent mental health services: issues and prospects.

Abstract For many years mental health services for children have been developed incrementally with little attention to the needs of the local population. However, over the past decade there have been attempts to develop more rational ways of planning child mental health services. This paper describes the information required to develop a needs-led child mental health service and, within that context, discusses how priorities should be set. It will be suggested that although the assessment of needs for child and adolescent mental health services is still very haphazard, there is now a clear trend for the evaluation of clinical practice to become more systematic. At an individual level we know quite a lot about the efficacy of treatment and the measurement of outcomes. At the service level, several models of good practice are being specified and evaluated.

Pathways from Adolescent Deliberate Self-Poisoning to Early Adult Outcomes: A Six-Year Follow-Up.

BACKGROUND Prospective studies show that the adult outcomes of adolescents who deliberately harm themselves are marked by high rates of adversity and psychiatric disorders. The goal of this study was to identify pathways linking childhood risk factors to early adult outcomes of suicidal adolescents. METHODS A clinical sample of 158 adolescents who deliberately poisoned themselves was followed up six years later. Eighty per cent of the cohort (n = 126) were interviewed in early adulthood using a battery of standardised measures of psychopathology and social functioning. RESULTS Multivariate mediation path analysis identified four pathways linking child and adolescent risk factors to adverse outcomes in early adulthood. Family dysfunction, conduct disorder and hopelessness contributed to the risk of high adversity in early adulthood indirectly through its effect on other risk domains, including dropping out of school and adopting adult roles at a younger age. Hopelessness not only predicted dropping out of school but also independently contributed to the risk of chronic major depressive disorder in early adulthood. Child sexual abuse independently predicted high adversity and chronic major depression over and above the influence of hopelessness. Juvenile onset major depression independently predicted chronic major depression in early adulthood. A substantial proportion of the effects of child sexual abuse and hopelessness on the risk of deliberate self-harm in early adulthood was mediated by high adversity and the duration of major depression. However, chronic major depression was the only risk factor independently associated with deliberate self-harm in adulthood once correlation with adversity was taken into account. CONCLUSIONS Chronic major depressive disorder is central to deliberate self-harm repetition. However, adult outcomes of suicidal adolescents are also dominated by the accumulating effects and consequences of other childhood risk factors, including child sexual abuse and adolescent hopelessness.

Early intervention and prevention for children excluded from primary schools

In the last 10 years, the problem of school exclusion in England has reached a crisis point. Figures on permanent exclusions from primary, secondary and special schools in England show that for 1996/97, 12 700 children were excluded. Among these, 12% were pupils permanently excluded from primary schools. When the present Labour Government came to office, it made tackling these interlinked problems, i.e. poverty, poor skills and high crime, a priority because of the great human costs to individuals and society, and because of the impact on public finances and the health of the economy. Therefore, the government launched in 1997 the Social Exclusion Unit as one the first governmental actions targeting the phenomenon of school and social exclusion. As part of these initiatives, this paper focuses on the prevention of exclusion from primary school and the first year of secondary school at Key Stages 1 and 2 (4–11 years old) due to emotional and behavioural problems either at home or at school. The study aims to establish whether a new intensive, multidisciplinary intervention for pupils excluded from primary school because of disruptive/antisocial behaviour helps reduce the number of excluded days and the reoccurrence of emotional and behavioural difficulties when compared with routine care.

Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial

Summary Background Self-harm in adolescents is common and repetition occurs in a high proportion of these cases. Scarce evidence exists for effectiveness of interventions to reduce self-harm. Methods This pragmatic, multicentre, randomised, controlled trial of family therapy versus treatment as usual was done at 40 UK Child and Adolescent Mental Health Services (CAMHS) centres. We recruited young people aged 11–17 years who had self-harmed at least twice and presented to CAMHS after self-harm. Participants were randomly assigned (1:1) to receive manualised family therapy delivered by trained and supervised family therapists or treatment as usual by local CAMHS. Participants and therapists were aware of treatment allocation; researchers were masked. The primary outcome was hospital attendance for repetition of self-harm in the 18 months after group assignment. Primary and safety analyses were done in the intention-to-treat population. The trial is registered at the ISRCTN registry, number ISRCTN59793150. Findings Between Nov 23, 2009, and Dec 31, 2013, 3554 young people were screened and 832 eligible young people consented to participation and were randomly assigned to receive family therapy (n=415) or treatment as usual (n=417). Primary outcome data were available for 795 (96%) participants. Numbers of hospital attendances for repeat self-harm events were not significantly different between the groups (118 [28%] in the family therapy group vs 103 [25%] in the treatment as usual group; hazard ratio 1·14 [95% CI 0·87–1·49] p=0·33). Similar numbers of adverse events occurred in both groups (787 in the family therapy group vs 847 in the treatment as usual group). Interpretation For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, our family therapy intervention conferred no benefits over treatment as usual in reducing subsequent hospital attendance for self-harm. Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents. Funding National Institute for Health Research Health Technology Assessment programme.

Lifetime and current costs of supporting young adults who deliberately poisoned themselves in childhood and adolescence

Background: Little is known about the long-term economic consequences of child and adolescent mental health problems, despite concerns that costs in later life may be significant. Aims: To evaluate current and lifetime costs of young adults who deliberately poisoned themselves in childhood. Method: Prospective cohort study of 129 young adults (mean age 21) who as teenagers had taken part in a randomized trial following deliberate self-poisoning. Lifetime and current costs of public sector services were calculated and compared to those of a matched general population control group. Results: The self-poisoning group incurred significantly greater lifetime costs than the controls. They used more service-provided accommodation, special education and hospital services, incurred greater criminal justice costs and received more social security benefits. Higher costs in the self-poisoning group were significantly associated with conduct disorder, hopelessness, previous suicide attempts, being male and being in care prior to the self-poisoning event. Conclusions: Child and adolescent mental health problems predict significant costs compared to general population controls. This study provides indications of those groups of young people who incur high costs and for whom early intervention should be considered.

Social work education in Cyprus: prospects and challenges in developing an indigenous character

ABSTRACT The evolution of the social work education and welfare system in Cyprus is inextricably linked to the country’s recent turbulent history. Social Work in the Republic of Cyprus, although shaped by the country’s turbulent political past and present, is also influenced by Western theory as in many other countries in the Asian and African continent [Gray, M., & Fook, J. (2004). The quest for a universal social work: Some issues and implications, Social Work Education, 23(5), 625–644; Rankopo, M. J., & Hwedie, K. O. (2011). Globalization and culturally relevant social work: African perspectives on indigenization. International Social Work, 54(1), 137–147; Yip, K. S. (2007). Tensions and dilemmas of social work education in China. International Social Work, 50(1), 93–105]. In contrast with social welfare which has a long history (since late nineteenth century), social work education is still at an early stage of development in Cyprus. A non-surprising situation given that social work practice and education, in its early stages, is essentially a modernist Western invention which has a history of silencing marginal voices and importing, into diverse cultural contexts across the world, Western thinking primarily from the UK and the USA (Gray & Fook, 2004). However, if an indigenous social work character is to be developed in Cyprus, and a more distinctive identity with regard to the social work academic curricula is to be demonstrated, then Payne’s [(2001). Knowledge bases and knowledge biases in social work. Journal of Social Work, 1(2), 133–136] views on social work knowledge need further exploration.