Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Brief psychodynamic interpersonal therapy after deliberate self-poisoning reduced suicidal ideation and deliberate self-harm

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ACP J Club. 2002 Jan-Feb;136:27. doi:10.7326/ACPJC-2002-136-1-027


Source Citation

Guthrie E, Kapur N, Mackway-Jones K, et al. Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ. 2001 Jul 21;323:135-8. [PubMed ID: 11463679]


Abstract

Question

In patients who have deliberately poisoned themselves, does brief psychodynamic interpersonal therapy (PIT) reduce suicidal ideation, severity of depression, and further episodes of self-harm and increase patient satisfaction?

Design

Randomized {allocation unconcealed*}†, blinded (outcome assessor),* controlled trial with 6-month follow-up.

Setting

A university hospital emergency department in Manchester, England, UK.

Patients

119 adults who were 18 to 65 years of age (mean age 31 y, 55% women), presented with an episode of deliberate self-poisoning, were registered with a general practitioner, and did not need inpatient psychiatric treatment. Follow-up was 80%.

Intervention

After stratification by history of self-harm, patients were allocated to four 50-minute sessions of PIT (n = 58) or to usual care (n = 61). PIT consisted of identifying and helping to resolve interpersonal difficulties that caused or exacerbated psychological distress. The therapy was described in a standardized manual.

Main outcome measures

Suicidal ideation (Beck Scale for Suicidal Ideation). Secondary outcomes were depression symptoms (Beck Depression Inventory), patient satisfaction (10-point scale, higher scores indicate higher satisfaction), and further episodes of deliberate self-harm.

Main results

Analysis was by intention to treat. After adjustment for baseline values, psychotherapy led to less suicidal ideation (P < 0.005) and less severe depression (P = 0.037) than did usual care (Table). The difference in depression scores was no longer statistically significant after adjustment for marital status. Patient satisfaction was higher for psychotherapy than for usual care (P = 0.015) (Table). Unadjusted rates for repeated self-harm were lower for psychotherapy than for usual care (P = 0.009) (Table).

Conclusion

In adults who have deliberately poisoned themselves, 4 sessions of psychodynamic interpersonal therapy reduced suicidal ideation and deliberate self-harm and increased patient satisfaction.

*See Glossary.

†Information provided by author.

Sources of funding: North West Regional Health Authority and NHS Research and Development Levy.

For correspondence: Dr. E. Guthrie, School of Psychiatry and Behavioural Sciences, University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Manchester M13 9WL, England, UK. FAX 44-161-273-2135.


Table. Psychodynamic interpersonal therapy (PIT) vs usual care (control) for deliberate self-poisoning‡

Outcomes at 6 mo Mean Scores Mean difference (95% CI)
PIT Control
Beck Scale for Suicidal Ideation 7.9 12.8 4.9 (1.6 to 8.2)
Beck Depression Inventory 18.8 23.7 5.0 (0.3 to 9.7)§
Patient satisfaction 5.5 3.9 1.6 (0.3 to 2.8)
Event Rates
PIT Control RRR (CI) NNT (CI)
Deliberate self-harm 8.6% 28% 69% (26 to 88) 6 (4 to 18)

‡Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article. Mean scores and differences were adjusted for baseline differences.
§Not statistically significant when adjusted for marital status.


Commentary

Rates of hospital attendance after self-harm are about 400 in 100 000 per year in the United Kingdom, and in persons who have committed suicide, 1 in 4 attended the hospital after a nonfatal act in the previous year. Under the circumstances, the evidence for the effectiveness of interventions is disappointing (1).

Guthrie and colleagues struggled with some familiar problems, and despite their best efforts, many exclusions and refusals of patients occurred; in the end, they included only 23% of presenting patients. We cannot be sure how generalizable their findings are, although patient baseline characteristics were typical for the United Kingdom.

Final numbers were respectable but were nonetheless relatively small, and possibilities exist for bias. For example, the treatment and control groups differed in marital status and psychiatric history. The authors adjusted for some potential confounders in their analysis but not for all. The apparently large effect of psychological therapy on the repeated self-harm rate needs to be viewed with caution.

The results of this trial are encouraging because they add to the evidence that brief psychological therapies improve outcomes after self-harm (2). Those who are sympathetic will accept the study findings as further evidence that patients with such a high burden of problems and risk for suicide should be offered treatment. Promising therapies (like the one evaluated here) are brief, have a strong focus on practical problem solving and interpersonal difficulties, and are delivered in a format that patients find acceptable.

For the skeptical, the evidence remains less than rock solid. We still need large multicenter trials to test the real-world effectiveness of psychological therapies before we can argue for their routine inclusion in clinical services.

Allan House, DM
University of Leeds
Leeds, UK

Allan House, DM
University of Leeds
Leeds, UK


References

1. Hawton K, Townsend E, Arensman E, et al. Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database Syst Rev. 2001;(3):CD001764.

2. Townsend E, Hawton K, Altman DG, et al. The efficacy of problem-solving treatments after deliberate se1f-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med. 2001;31:979-88.