Introduction

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Deliberate self poisoning is one of the commonest reasons for medical admission in the United Kingdom.¹ Of patients presenting to hospital with deliberate self poisoning, 3% to 15% eventually kill themselves.^2-4 However, services for this problem remain poorly organised,⁵ probably because there are no interventions of proved efficacy. A recent systematic review concluded that while some treatments showed promise, further randomised intervention trials were required.⁶

About 70% of all episodes of deliberate self harm are precipitated by an interpersonal problem,⁷ so there is a strong rationale for investigating the efficacy of an interpersonal intervention. We used a randomised controlled trial to determine whether a brief psychological treatment compared with usual treatment for deliberate self poisoning results in decreased suicidal ideation, reduced severity of depressive symptoms, and a reduction in further episodes of self harm.

	Methods

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The study was conducted at the emergency department of a university hospital. Patients between the ages of 18-65 years were considered eligible for the study if they presented with an episode of deliberate self poisoning.⁸ Participants had to be able to read and write English, be living within the catchment area of the hospital, be registered with a general practitioner, and not need inpatient psychiatric treatment.

Consecutive patients meeting inclusion criteria were invited to take part in the study by the emergency department doctor who assessed them at the time of presentation. The study was then explained in detail by one of the research team (FM-F, EM), who was not involved in any other aspect of their treatment. After the patient gave signed consent, the recruiting member of the research team referred to a allocation sequence, provided by the trial statistician (BT) and based on a computer generated list of random numbers, to assign patients to the psychotherapy intervention or usual treatment in blocks of 12 participants. The groups were stratified according to whether or not they had a history of self harm.

Psychotherapy intervention
Patients in the intervention group were offered four sessions of psychodynamic interpersonal therapy within one week of presentation. This therapy entails identifying and helping to resolve interpersonal difficulties which cause or exacerbate psychological distress. The model was developed by Hobson⁹ and is described in a standardised manual.¹⁰ It has proved efficacy in the treatment of depression ^{11 12} and has been shown to be cost effective.¹³

Usual care
Patients who were randomised to the "treatment as usual" arm received routine care. In most cases this consists of an assessment by a casualty doctor or a junior psychiatrist in the emergency department, on the basis of which about one third patients are referred for follow up as a psychiatry outpatient, a small number are referred to addiction services, and the remainder are advised to consult their own general practitioner.⁵ No patients are routinely referred to psychotherapy or psychology services.

Outcome measures
We considered suicidal ideation as our primary outcome measure because it is an important predictor of successful suicide.¹⁴ We took a difference of 5 points on the Beck scale for suicidal ideation to be clinically significant.¹⁵ The standard deviation (SD) of this scale in a previous study was 7.7.¹⁶ Assuming =0.05 and =0.2 and allowing for a one third drop out rate, we calculated we would need to recruit 60 patients to each group. We considered depressive symptoms, patients' satisfaction with their treatment, and repetition of deliberate self harm as secondary outcome measures.

Episodes of self harm
Patients were asked to give a detailed description of further episodes of self harm at one month and six month assessments. Episodes were included if they met a standard definition.⁸ In addition, a separate check of the hospital database was carried out by a researcher (NK), blind to the trial groups, to determine whether patients lost to follow up had presented with deliberate self harm during the study period. We recorded all methods of self harm, including self poisoning.

Resource utilisation
We collected information on use of health services at each assessment on the basis of a well established method for recording data on health economics.¹⁹ Follow up assessments were conducted by one of two research assistants (EM, FM-F), who were blind to treatment groups. The study was granted ethical approval from the Central Manchester ethics committee.

Data analysis
We included in the analysis all patients who completed the assessments at the end of treatment or at six month follow up assessments. Comparisons between groups were made on an intention to treat basis. Patients were included in the groups to which they were allocated after randomisation regardless of how long, or even whether, they received the treatment assigned. We compared normally distributed variables using t tests and used analysis of covariance in the comparisons at follow up to adjust for baseline differences.

	Results

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During the recruitment phase of the study 587 adults presented with deliberate self poisoning. Of these, 354 were ineligible. The figure shows progress through the study. Of the 233 patients eligible for the study, 119 (51%) agreed to participate. They were similar to those who declined in terms of sex and employment status but were more likely to have a history of self harm (59% v 45%), to have left a suicide note at the time of the current episode (23% v 5%), and to express a wish to die (76% v 46%).

View larger version (44K): [in this window] [in a new window]   Progress of participants through trial

Of the 119 participants, 66 (56%) were women and the mean (SD) age was 31.2 (1.5) years. Thirty three patients (28%) were married or cohabiting, and 19 (16%) were in paid employment. Paracetamol was the drug most commonly chosen for self poisoning (36% of patients). Seventy one (60%) had a history of self harm, and 67 (56%) had a history of psychiatric treatment. The intervention and usual treatment groups were similar in terms of baseline characteristics with the exception of marital status (table 1).

Psychological assessments were completed on 89 (75%) patients at the end of the treatment phase and 95 (80%) patients at six month follow up. Patients assessed at follow up were similar to those lost to follow up in terms of baseline clinical and demographic characteristics. The mean (SD) baseline score on the Beck scale for suicidal ideation for those who completed questionnaires at six months was 15.9 (10.5) compared with 11.7 (9.3) for those who did not complete a questionnaire at six months.

Symptom measures
Patients who received psychotherapy showed greater improvement on the outcome measures than patients in the control group at six month assessment (table 2). When we adjusted for differences in marital status between the groups, the differences in the scores on the Beck scale for suicidal ideation remained significant (P=0.027) but the scores for the Beck depression inventory did not (P=0.11).

Satisfaction
Patients who received the intervention were more satisfied with their treatment at the end of therapy (mean (SD) satisfaction scores 6.56 (3.42) v 4.40 (3.08), 95% confidence interval for difference in means 0.73 to 3.58, P=0.003, t test) and at six month follow up (5.46 (3.38) v 3.89 (2.76), 0.31 to 2.83, P=0.015).

Further episodes of self harm
Twenty nine patients harmed themselves again during the study period. Twenty one patients reported doing so without seeking hospital treatment, and six reported attending hospital. We found data on two further patients on the computerised database. At six month follow up five patients (9%) in the intervention group had harmed themselves again compared with 17 patients (28%) in the usual treatment group (P=0.009, Fisher's exact test, difference in proportion 19.3%, 8.6% to 30.0%). There were no successful suicide attempts in either group during the follow up period.

Resource utilisation
During the treatment phase of the study the two groups were similar in terms of contact with psychiatrists, but patients in the intervention group had more contact with a psychiatric nurse than those in the usual treatment group (mean number (range) of contacts 2 (1-4) v 0.16 (0-3)). Table 3 shows health service contacts for the six months after the intervention.

	Discussion

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Inpatients who poison themselves deliberately we have shown that suicidal ideation and self reported self harm were reduced after brief psychological intervention. Patients who received the therapy also reported higher levels of satisfaction with their treatment. There was no evidence from the data on use of health services that the intervention resulted in a reduction in such use. Our previous research suggests that a more intensive therapeutic intervention may be required to effect such a change.¹³

Methodological considerations
We made no attempt to control for the non-specific effects of psychotherapy in this study as the trial was a pragmatic one. We aimed to compare a specific intervention with the usual treatment in the United Kingdom for patients who harm themselves.²⁰ Effects of treatment may have resulted from non-specific factors, such as increased contact with nurses for patients in the intervention group. However, previous studies that have involved a similar or greater intensity of clinical contact have failed to show benefit on several outcomes, ^{21 22} and psychodynamic interpersonal therapy has already been found to be superior to a psychological placebo in other patient groups.²³

Possible explanations for treatment effects
Why has the current study shown clear treatment effects, in contrast with previous research? The intervention in the current study focused specifically on interpersonal problems, which are an important antecedent of many episodes of self harm.⁷ Our sample included a high proportion of patients with a history of self harm, who may particularly benefit from psychological treatments.⁶ Lastly, our measure of repetition included episodes of self harm when the patient did not present to hospital.

Conclusion
These results are promising, but larger studies of interpersonal psychotherapies in different settings are needed to establish the potential costs and benefits of such treatments for patients who poison themselves. Studies comparing psychodynamic interpersonal therapy with placebo treatments and other psychological interventions may help to identify the active components of the therapy. Such research would inform our future approaches to a problem which is both difficult to manage and widespread.

	Acknowledgments

We thank the following people for supporting the project: Dr Rosemary Morton, (consultant in accident and emergency medicine), Simon Brown (nursing manager, accident and emergency), Drs David Hughes, Damien Longson, Amanda Poynton, Judy Harrison, Ian Anderson, Andrew Procter, Sarah Davies, and Richard Gater (consultant psychiatrists, community mental health team), and Frank Hanily and Mary Lord (managers in the directorate of psychiatry, community mental health team). We also thank Professor Francis Creed for his comments on the manuscript.

Contributors: EG designed the study and sought funding. EG, NK, KM-J, CC-G, JM, and BT contributed to aspects of study design. SS, CT, and GB delivered the therapy and were supervised by EG and JM. EM and FM-F carried out the follow up assessments. EG, NK, and BT carried out the data analyses. EG and NK produced the initial draft of the paper, and all authors commented on the drafts. EG is the guarantor for the study.

	Footnotes

Competing interests: None declared.

Funding: North West Regional Health Authority and the NHS Research and Development Levy.

	References

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1.	NHS Centre for Reviews and Dissemination. Deliberate self harm. Effective Health Care 1998; 4: 1-12.
2.	Hawton K, Fagg J. Suicide and other causes of death following attempted suicide. Br J Psychiatry 1988; 152: 359-366[Abstract/Free Full Text].
3.	Hall DJ, O'Brien F, Stark C, Pelosi A, Smith H. Thirteen-year follow-up of deliberate self-harm, using linked data. Br J Psychiatry 1998; 172: 239-242[Abstract/Free Full Text].
4.	Nordentoft M, Breum L, Munck L, Nordestgaard A, Hunding A, Bjaedager P. High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts. BMJ 1993; 306: 1637-1641.
5.	Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E. Management of deliberate self poisoning in adults in four teaching hospitals: descriptive study. BMJ 1998; 316: 831-832[Free Full Text].
6.	Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R, et al. Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ 1998; 317: 441-447[Abstract/Free Full Text].
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13.	Guthrie E, Moorey J, Margison F, Barker H, Palmer S, McGrath G, et al. Cost-effectiveness of brief psychodynamic-interpersonal therapy in high utilizers of psychiatric services. Arch Gen Psychiatry 1999; 56: 519-526[Abstract/Free Full Text].
14.	Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985; 142: 559-563[Abstract/Free Full Text].
15.	Beck AT, Kovacs M, Weissman A. Assessment of suicide intention: the scale for suicide ideation. J Consult Clin Psychol 1979; 47: 343-352[CrossRef][Medline].
16.	Steer RA, Rissmiller DJ, Ranieri WF, Beck AT. Dimensions of suicidal ideation in psychiatric inpatients. Behav Res Ther 1993; 31: 229-236[CrossRef][Medline].
17.	Beck AT, Steer RA, Ranieri WF. Scale for suicidal ideation: psychometric properties of a self report version. J Clin Psychol 1988; 44: 499-505[Medline].
18.	Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561-571.
19.	Beecham J, Knapp N. Costing psychiatric interventions. In: Thornicroft G, Brewin CR, Wing J, eds. Measuring mental health needs. London: Royal College of Psychiatrists, 1992:163-183.
20.	Slinn R, King A, Evans J. A national survey of the hospital services for the management of adult deliberate self-harm. Psychiatric Bull 2001; 25: 53-55.
21.	Hawton K, McKeown S, Day A, Martin P, O'Connor M, Yule J. Evaluation of out-patient counselling compared with general practitioner care following overdoses. Psychol Med 1987; 17: 751-761[Medline].
22.	Van der Sande R, Van Rooijen L, Buskens E, Allart E, Hawton K, Van Der Grafe Y, et al. Intensive in-patient and community intervention versus routine care after attempted suicide. A randomized intervention study. Br J Psychiatry 1997; 171: 35-41[Abstract/Free Full Text].
23.	Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991; 100: 450-457[Medline].

(Accepted 17 April 2001)

Commentary: Another kind of talk that works?

George C Patton, professor. 

Departments of Paediatrics and Psychiatry, University of Melbourne, Melbourne, Australia

Correspondence to: Centre for Adolescent Health, William Buckland House, Parkville 3052, Australia

Patients presenting to emergency departments after deliberately harming themselves are an important problem. Rates of concomitant psychiatric disorder are high and crude mortality may reach 10% within a decade.¹ Such presentations should offer good opportunities for clinical intervention. Given this, it is striking that deliberate self harm has remained such an elusive target. The paper by Guthrie et al from Manchester suggests that a brief psychotherapeutic intervention, based in part on a psychodynamic approach, may be an effective treatment. The findings have implications not only for the management of suicidal behaviour but also for views on what kind of psychotherapy works.

The trial compared psychodynamic interpersonal psychotherapy given once a week for four weeks by nurses practitioners with normal management. It combined elements of outreach (visiting patients at home) with a psychotherapy focused on the individual's current difficult relationships. Their findings that suicidal ideation and self report of further self harm were reduced in the intervention group at six month follow up carry important implications for medical responses to patients who harm themselves. They stand in contrast with results of previous trials, which have failed to produce consistent evidence of positive effect.²

This study is notable for positive features, including an efficient block randomised design, good participation rates of those randomised, and high tracing rates at six months. It has not, however, avoided all the methodological problems that have clouded interpretation of studies in this topic. The study was of a modest size, raters were not blind to the intervention status of patients at follow up, and retrospective self report was the only assessment for subsequent self harm. Low rates of uptake of the intervention were a further limitation, with only a fifth of those presenting eventually coming into the trial. The authors note that the severity of symptoms in participants at the outset was similar to that found in earlier trials, but it still leaves open a question of the feasibility of this approach in the majority of those presenting with an overdose.

These limitations in mind, the findings remain impressive. The patients reported substantial reductions in both suicidal ideation and depressive symptoms that could not be explained by differential contact with health services. The reduction in further episodes of self harm seems stronger than in earlier studies, even though rates of self harm in the comparison group were consistent with those found in controls in previous reports.

In the past decade it has become clear that focal psychotherapies are effective for the treatment of a range of common psychiatric and behavioural problems.³ Much of the evidence has concerned cognitive behavioural approaches. The current study adds to the evidence, some of it from the lead author, that focal psychodynamic approaches might also be effective and viable in terms of cost. ^{4 5} It is another indicator of the need for randomised trials to move the debate around psychotherapy into an evidence based arena. A first step must be replication of studies of this kind in bigger samples and different locations. Beyond that, the hope is that the debate moves from whether psychotherapy works to questions of how well do specific psychotherapies work in the range of clinical problems and contexts in which they might be indicated.

	References

1.	Nordentoft M, Breum L, Munck LK. High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts. BMJ 1993; 306: 1637-1641.
2.	Hawton K, Arensman E, Townshend E, Bremner S, Feldman E, Goldney R, et al. Deliberate self harm: a systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ 1998; 317: 441-447.
3.	Andrews G. Talk that works: the rise of cognitive behaviour therapy. BMJ 1996; 313: 1501-1502[Free Full Text].
4.	Guthrie E, Moorey J, Margison F, Barker H, Palmer S, McGrath G. Cost-effeciveness of brief psychodynamic-interpersonal therapy in high utilizers of psychiatric services. Arch Gen Psychiatry 2001; 56: 519-526.
5.	Guthrie E, Creed F, Dawson D, Tompson M. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991; 100: 450-457.