Group Therapy for Repeated Deliberate Self-Harm in Adolescents: Failure of Replication of a Randomized Trial

doi:10.1097/CHI.0b013e3181aOacec

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 48, Issue 6, June 2009, Pages 662-670

https://doi.org/10.1097/CHI.0b013e3181aOacec Get rights and content

Abstract

Objective

To replicate a study, which found group therapy superior to routine care in preventing the recurrence of self-harming behavior in adolescents who had deliberately harmed themselves on at least two occasions.

Method

Single blind study with parallel randomized groups undertaken in three sites in Australia. The primary outcome measure was repetition of self-harm, assessed on average after 6 and 12 months. Secondary outcome measures included suicidal ideation, psychiatric disorder, and service use.

Results

Seventy-two adolescents aged 12 to 16 years (91% female subjects) were randomized to group therapy or routine care. Primary outcome data were available for 68 of the 72 randomized participants. More adolescents randomized to group therapy than those randomized to routine care had self-harmed by 6 months (30/34 versus 23/34, χ² = 4.19, p = .04), and there was a statistically nonsignificant trend for this pattern to be repeated in the interval of 6 to 12 months (30/34 versus 24/34, χ² = 3.24, p = .07). There were few differences between the treatment groups on secondary outcome measures, other than a trend for greater improvement over time on global symptom ratings among the experimental group compared with the control group.

Conclusions

Our findings contradict those of the original study. Some differences in participant characteristics between the studies, along with less experience at the Australian sites in delivering the intervention, may have accounted for the different outcome. The benefit of group therapy for deliberate self-harm is unproven outside the environment in which it was originally developed. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(6):662–670.

Section snippets

Entry Criteria

Participants were eligible if they were aged between 12 and 16 years, had been referred to a child and adolescent mental health service in Australian sites at Newcastle, Brisbane North, or Logan, and reported at least two episodes of self-harm in the past year, one of which had occurred in the past 3 months. Deliberate self-harm was defined as any intentional self-inflicted injury (including poisoning) irrespective of the apparent purpose of the behavior. Poisoning as a result of excessive use

Participant Characteristics

The demographic and clinical characteristics of the randomized participants, organized by treatment group, are summarized in Table 1. Comparison groups were well matched on most variables, the exception being medication overdose, which was more prevalent in the experimental group than the routine care group.

The participants commonly engaged in multiple types of self-harm, which were reported with the following rates: cutting, 97%; head banging, 71%; medication overdose, 57%; smothering, 36%;

Discussion

We sought to determine if a form of group psychotherapy developed in Manchester in the United Kingdom would translate to the Australian setting and be more effective than routine care in reducing the recurrence of self-harm in a clinical sample of teenagers treated in Brisbane, Logan North or Newcastle. In contrast to the first published evaluation of the group psychotherapy,¹⁵ we found a tendency for more participants in the experimental group than the routine care group to engage in self-harm

Conclusions

We failed to replicate a finding from a British study that group psychotherapy reduces the likelihood of self-harm repetition among adolescent mental health outpatients. In our study, there was greater tendency for those randomized to the experimental group to continue to self-harm than there was for those randomized to routine care, although this could be an artifact arising from baseline differences in rates of previous medication overdose. There was a tendency for those randomized to the

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Cited by (99)

A meta-analysis of targeted interventions for reducing suicide-related behaviour and ideation in adolescents: Implications for trial design
2023, Comprehensive Psychiatry
Suicidality among young people is a significant societal issue. The current study conducted a meta-analysis of community and clinical interventions targeting suicide attempts, self-harm, and suicidal ideation in adolescents.
Interventions targeting suicide attempts, self-harm and suicidal ideation were identified by searching PsychINFO, Medline, CINAHL and Embase in line with the PRISMA statement. Study quality was determined using a risk of bias tool. Meta-analyses examined the efficacy of the interventions. Effect sizes were calculated for suicidal ideation data (continuous data) using Hedge's g for standardised mean differences. Suicide attempts and self-harm (dichotomous data) were calculated using odds ratios (ORs).
Seventeen RCTs were included in the meta-analysis. No significant differences were found between treatment and control groups on measures of suicide attempts or self-harm. A small effect-size was observed on measures of suicidal ideation (g = 0.47). A secondary meta-analysis investigated change over time in treatment as usual conditions, finding significant large effect-sizes for suicide attempts (OR = 18.67), self-harm (OR = 12.77), and suicidal ideation (g = 0.86).
The methodological decision to focus on specific outcomes over a broad definition of self-harm excluded some papers, which have been included in other reviews. It is unlikely to have significantly affected the overall results. The review was not preregistered.
These twin findings highlight the importance overcoming the methodological difficulty of discerning effective interventions during a period of baseline improvement. We suggest that future trials should move away from broadly addressing “suicidality/self-harm” and encourage a greater targeting of at-risk individuals.
Twenty-six years of psychosocial interventions to reduce suicide risk in adolescents: Systematic review and meta-analysis
2022, Journal of Affective Disorders
During adolescence, suicide risk increases; effective treatments are needed to reduce risk.
Databases were searched (1995–2020) for randomized controlled trials (RCTs) concerning psychosocial treatments for suicide prevention in adolescents (10–18 yrs). Data were extracted from the timepoint closest to 6 months. Cohen's ds were estimated for reducing suicidal ideation (SI), self-harming behaviors (SHB) excluding strictly non-suicidal self-injury, and suicide attempts (SA) and analyzed using generalized least square regression. Meta-analytic innovations included within-person correlations to reflect trait suicidality; annualization to control for exposure; estimated lifetime risk based on ages; and modeling inclusion/exclusion criteria. Alternate approaches included relative risk and comparison of intervention and control treatments to baseline.
Of 30 RCTs, 6 assessing SHB (4 measuring SA), and 7 assessing SI demonstrated treatment effectiveness. Overall, interventions decreased SI (n = 25) with low effect size (d = 0.08, p = 0.01), non-significant after controlling for publication bias (d = 0.05, p = 0.1); interventions were non-significant for SHB (n = 25, d = 0.001, p = 0.97) or SA (n = 18, d = 0.03, p = 0.52). To prevent one SHB, the number needed to treat (NNT) was 45[26,156]; for SA, NNT=42[24,149]. Non-superiority may relate to effectiveness of control treatments. Thus, experimental and control treatments also were compared to baseline: both reduced SI (p < 0.0001), and effectiveness improved for SHB (NNT=12) and SA (NNT=11).
Study heterogeneity and inconsistent statistical reporting limited meta-analysis.
Psychosocial interventions for suicide risk in adolescents showed little effectiveness compared with control treatments; suicide outcomes improved in both groups compared to baseline. Different approaches may be needed, including precision medicine methodologies and standardized statistical reporting criteria.
Cognitive behavioral therapy for suicide prevention in youth admitted to hospital following an episode of self-harm: A pilot randomized controlled trial
2020, Journal of Affective Disorders
Self-harm (SH) is among the strongest risk factors for eventual suicide death yet there are limited data on which interventions are most effective for treating SH in youth.
This single-blind, pilot randomized controlled trial examined brief cognitive behavioral therapy (BCBT) for suicide prevention vs. minimally-directive supportive psychotherapy in youth (aged 16–26) hospitalized following SH. Both therapies included 10 acute sessions over 15 weeks with three booster sessions occurring at three month intervals thereafter. The primary feasibility outcome was ≥70% retention at study endpoint. Efficacy measures, including repeat SH, were secondary outcomes.
Twenty-four subjects were enrolled (12 per group) with one BCBT subject and two controls dropping out prior to the first therapy session. Five (45%) of the remaining BCBT subjects and seven (70%) control subjects completed all 10 acute therapy sessions. All subjects who completed five sessions went on to complete 10. There were significantly fewer instances of repeat SH in BCBT subjects (7 of 62 weeks of acute follow-up; 11%) compared to control subjects (24 of 79 weeks; 30%)(OR 0.34, 95%CI:0.13–0.92). Three subjects, all in the control condition, made a total of five suicide attempts during the study.
This study had a modest sample size and retention rate.
This study failed to achieve its primary feasibility retention goal for BCBT. However, it did demonstrate that initial adherence to follow-up predicted study completion. Despite small numbers, it also found a significant reduction in repeat SH in the BCBT group, a finding which requires replication.
Self-harm, depressive mood, and belonging to a subculture in adolescence
2019, Journal of Adolescence
Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: Impact of content and quality on outcomes in a systematic review
2018, Journal of Affective Disorders
Citation Excerpt :
Offering psychotherapy in a group-based environment may provide a number of additional beneficial effects beyond the hypothesized mechanism of change for this intervention, such as helping participants overcome social isolation. Alternatively, offering treatment in a group-based format may be detrimental for this patient group, given findings from one Australian trial of group-based CBT with adolescent self-harm patients in which information shared during a group-based psychotherapy session was posted on a participant's personal web-blog (Hazell et al., 2009). There may also be more detrimental effects of group-based CBT when self-harm patients with a history of frequent self-harm repetition are involved, as they may be particularly vulnerable to the social contagion effects of self-harm (Haw et al., 2013).
Randomized controlled trials (RCTs) are the mainstay of evaluations of the efficacy of psychosocial interventions. In a recent Cochrane systematic review we analysed the efficacy of cognitive behavioural-based psychotherapies compared to treatment as usual (TAU) in adults who self-harm. In this study we examine the content and reporting quality of TAU in these trials and their relationship to outcomes.
Five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched for RCTs, indexed between 1 January 1998 and 30 April 2015, of cognitive-behavioural interventions compared to TAU for adults following a recent (within six months) episode of self-harm. Comparisons were made between outcomes for trials which included different categories of TAU, which were grouped as: multidisciplinary treatment, psychotherapy only, pharmacotherapy only, treatment by primary care physician, minimal contact, or unclear.
18 trials involving 2433 participants were included. The content and reporting quality of TAU varied considerably between trials. The apparent effectiveness of cognitive behavioural psychotherapy varied according to TAU reporting quality and content. Specifically, effects in favour of cognitive-behavioural psychotherapy were strongest in trials in which TAU content was not clearly described (Odds Ratio: 0.29, 95% Confidence Interval 0.15–0.62; three trials) compared to those in which TAU comprised multidisciplinary treatment (Odds Ratio: 0.79, 95% CI 0.63 to 0.97; 12 trials).
The included trials had high risk of bias with respect to participant and clinical personnel blinding, and unclear risk of bias for selective outcome reporting.
TAU content and quality represents an important source of heterogeneity between trials of psychotherapeutic interventions for prevention of self-harm. Before clinical trials begin, researchers should plan to carefully describe both aspects of TAU to improve the overall quality of investigations.
What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis
2018, EClinicalMedicine
Citation Excerpt :
One study did not use ITT, but conducted a sensitivity analysis to assess the robustness of the findings [70]. Nineteen (57·6%) reported less than 15% drop out and were classed as low risk for the purpose of meta-analysis [41,43–46,49–51,53,54,56,58,61,63–69]. All nineteen studies in this category tested indicated therapeutic interventions.
Young people require specific attention when it comes to suicide prevention, however efforts need to be based on robust evidence.
We conducted a systematic review and meta-analysis of all studies examining the impact of interventions that were specifically designed to reduce suicide-related behavior in young people.
Ninety-nine studies were identified, of which 52 were conducted in clinical settings, 31 in educational or workplace settings, and 15 in community settings. Around half were randomized controlled trials. Large scale interventions delivered in both clinical and educational settings appear to reduce self-harm and suicidal ideation post-intervention, and to a lesser extent at follow-up. In community settings, multi-faceted, place-based approaches seem to have an impact. Study quality was limited.
Overall whilst the number and range of studies is encouraging, gaps exist. Few studies were conducted in low-middle income countries or with demographic populations known to be at increased risk. Similarly, there was a lack of studies conducted in primary care, universities and workplaces. However, we identified that specific youth suicide-prevention interventions can reduce self-harm and suicidal ideation; these types of intervention need testing in high-quality studies.

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The research was supported by the American Foundation for Suicide Prevention.

Clinical trial registration information–Group Psychotherapy to Reduce the Repetition of Self-Harm in Adolescents. URL: http://www.ANZCTR.org.au. Unique identifier: ACTRN12608000532303.

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New ResearchGroup Therapy for Repeated Deliberate Self-Harm in Adolescents: Failure of Replication of a Randomized Trial

Abstract

Objective

Method

Results

Conclusions

Section snippets

Entry Criteria

Participant Characteristics

Discussion

Conclusions

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Suicide and Hospitalised Self-Harm in Australia

The aftercare of adolescents with deliberate self-harm

J Child Psychol Psychiatry

Repetition risk for adolescent self-poisoning: a multiple event survival analysis

Aust N Z J Psychiatry

Social skills and depression in adolescent suicide attempters

Adolescence

Common problems and coping strategies. II: Findings with adolescent suicide attempters

J Abnorm Child Psychol

Controlled studies of psychosocial intervention following attempted suicide

Self-mutilation and coping strategies in a college sample

Suicide Life Threat Behav

Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers

J Consult Clin Psychol

Treatment strategies for adolescent suicide attempters

New Research
Group Therapy for Repeated Deliberate Self-Harm in Adolescents: Failure of Replication of a Randomized Trial