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Psychosocial and pharmacological treatments for deliberate self harm

  • Review
  • Intervention

Authors


Abstract

Background

Deliberate self-harm is a major health problem associated with considerable risk of subsequent self-harm, including completed suicide.

Objectives

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.

Search methods

Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted.

Selection criteria

All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm.

Data collection and analysis

Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution).

Main results

A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0.47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0.09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93).

Authors' conclusions

There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

摘要

背景

蓄意自殘的心理社會治療及藥物治療

蓄意自殘是一個重大的健康議題,因為它和進一步(或重複)的自殘甚至自殺有相當程度的關聯。

目標

找尋與整合先前有關蓄意自殘病人治療方式之隨機對照試驗。

搜尋策略

電子資料庫搜尋:MEDLINE (from 1966 – 1999二月); PsycLit (from 1974 – 1999三月); Embase (from 1980 – 1999一月); The Cochrane Controlled Trials Register (CCTR) No.1 1999. 十篇在精神及心理學領域的論文在第一次檢視時被搜尋到。另外我們也搜尋了三篇有關自殺這個領域1998年以前發表的論文。論文索引已被確認,而作者也都被連絡告知。

選擇標準

所有較為積極的心理社會及心理藥物治療模式去比較其他標準或較不積極的照護模式,針對蓄意自殘病人(無論是服用毒藥或是自我傷害, 都歸類在蓄意自殘)治療效果的隨機對照試驗。

資料收集與分析

資料的選取是由獨立的兩位檢視者從原始論文選出。研究則根據治療的方式歸類。用來評估對蓄意自殘病人治療是否有效則是利用重複自殺行為的比例。從研究論文中,我們無法檢視其他如病人對治療的順從性、憂鬱、無望、自殺的想法、所面臨的問題及問題解決狀態的改變等。

主要結論

總共二十三篇試驗選入, 都是以蓄意自殘的再發生次數當作結果變數。這些試驗被分成十一個類別。整合後的勝算比雖未達統計上的顯著差異但卻顯示一個趨勢:問題解決導向的治療模式比標準治療模式(0.70; 0.45 to 1.11)以及提供緊急連絡卡加上標準治療模式比單純只有標準治療模式(0.45; 0.19 to 1.07)更能減少再度蓄意自殘。較積極的自殘後照顧加上延伸照護比較於標準照護的整合勝算比則是0.83 (0.61 to 1.14),至於抗憂鬱藥物對比於安慰劑的勝算比則是0.83 (0.47 to 1.48)。剩餘的比較都是單一小型試驗。其他減少自殘的比較如:flupenthixol對比於安慰劑的勝算比是0.09 (0.02 to 0.50),以及自殘後行為治療對標準照護的勝算比是0.24(0.06 to 0.93)。

作者結論

關於哪種形式的心理社會與生理(藥物)治療對自殘病人的治療最有效,目前尚有不確定性,主要因素是這些試驗的病人數不足。因此,尚需大型治療試驗去研究那種治療模式對減少重覆自殘的比例最具效果。小型試驗若在統計學上發現差異,其解讀要很小心,確定結果為為真之前應要重新驗証檢視。

翻譯人

本摘要由臺北榮民總醫院郭俊麟翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

需要更多的證據來決定哪一種治療方式對蓄意自殘的病人最有效。蓄意自殘是一個重要的健康議題,因為它有可能演變成自殺。此系統性回顧是要評估各個蓄意自殘的治療模式,針對其是否能有效預防之後的自殺行為。這二十三個隨機對照試驗的結果顯示尚需更多的證據來決定哪一種治療方式最有效。較有展望的發現包括針對重複自殘及女性邊緣性人格重複自殘的病人給予長期心理社會治療、以問題解決導向的治療模式、提供緊急連絡卡服務、以及flupenthixol藥物的治療等。然而因為試驗中病人數不足限制了結論的可靠性,之後還需要更多大型試驗來驗證。

Plain language summary

Psychosocial and pharmacological treatments for deliberate self harm

Deliberate self-harm is a major health problem associated with considerable risk of subsequent self-harm, including completed suicide. This systematic review evaluated the effectiveness of various treatments for deliberate self-harm patients in terms of prevention of further suicidal behaviour. From the results of 23 randomized controlled trials the reviewers concluded that more evidence is required to indicate what the most effective care is for this large patient population. Promising results were found for problem-solving therapy, provision of a card to allow emergency contact with services, depot flupenthixol for recurrent repeaters of self-harm and long-term psychological therapy for female patients with borderline personality disorder and recurrent self-harm. However, insufficient numbers of patients in nearly all trials limit the conclusions that can be reached. More evidence is required to determine the most effective treatment for deliberate self-harm patients and larger trials are badly needed.

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