Self-harm is outlined as “intentional self-poisoning or damage, no matter the obvious function” (Nationwide Institute for Well being and Care Excellence, 2022, p. 81). Charges of self-harm have turn out to be extra prevalent, with 25.7% of ladies, and 9.7% of males, reporting self-harm throughout their life (McManus et al., 2016). Differential charges of self-harm have been reported for individuals who establish as LGBTQ+ (Liu et al., 2019), these from non-white ethnic backgrounds (Bhui et al., 2007) and people from disadvantaged socio-economic backgrounds (Geulayov et al., 2022). Self-harm can be linked with suicidality (Geulayov et al., 2019). Total, self-harm is a fancy and life-threatening phenomenon; one which warrants vital consideration.
The current examine, by Stevens and colleagues (2024), seeks to establish whether or not a short textual content message intervention may help in decreasing the variety of instances that folks have to return to hospital for self-harm therapy. The randomised managed trial (RCT), by Steven and colleagues (2024), is the primary to discover any such intervention on a broader inhabitants in Australia. Earlier analysis has been targeted on particular populations, like army personnel, subsequently, this examine has the potential to contribute to the interventions’ generalisability to a wider group of individuals.
May temporary textual content messages scale back the variety of instances folks have to re-present to hospital for self-harm therapy?
Strategies
Stevens et al., (2024) performed a parallel RCT which in contrast individuals who acquired therapy as standard (TAU), with individuals who acquired TAU, plus 9 temporary quick message service (SMS) messages over 12 months, after their discharge from three hospitals in New South Wales, Australia.
The SMS intervention included three completely different messages despatched to individuals on a rotating schedule. All SMS messages had been personalised with the individuals identify, included an expression of concern for participant wellbeing, and included particulars of accessible native psychological well being companies and disaster strains. The messages had been developed by consultants with lived expertise.
As soon as enrolled, individuals had been stratified by first and subsequent self-harm presentation as there was vital variability amongst individuals. After stratification, individuals had been then randomly assigned and enrolled by clinicians into both the TAU or TAU plus SMS situation. The allocation sequence was hid.
The examine additionally apparently used a single-consent Zelen design (Zelen, 1979) which has been mentioned in earlier a earlier weblog by Lucy Maconick (2022). The Zelen design is a modification to a standard RCT, whereby individuals within the intervention group solely are requested to supply consent after randomisation. Because the examine used a Zelen design, this meant that the individuals weren’t blinded to being within the SMS situation.
Outcomes
The examine enrolled 431 individuals into the TAU group and 373 individuals into the TAU plus SMS group. There was a bigger proportion of females (n=520) to males (n=284). The examine had fundamental three main outcomes, and two secondary outcomes.
Main outcomes
- The variety of instances that folks repeated self-harm, and wanted hospital therapy for this, decreased considerably at 12 and 24 months, after receiving TAU plus the SMS intervention, with a relative danger discount (RRR) of twenty-two%. The authors state that on the 24-month follow-up, this 22% equates to 123 much less folks re-presenting for self-harm therapy within the SMS group.
- Females had increased charges of re-presentation for self-harm, however the impact of the temporary textual content message was vital and bigger for females in comparison with males, the place there was no distinction between TAU and TAU plus intervention relating to the frequency of repeat, hospital handled, self-harm.
- There was no distinction, between TAU and TAU plus intervention, within the time between when individuals first offered to hospital with self-harm, to once they offered to hospital once more for self-harm, over the 24-month follow-up interval.
Secondary outcomes
- There was no distinction between TAU and TAU plus intervention relating to the proportion of individuals who repeated self-harm or not, over the 24-month follow-up interval of the examine, that means the intervention didn’t scale back the variety of instances folks repeated self-harm.
- All through the examine, over the 24-month interval, there have been a complete of 16 deaths.
- The examine additionally analysed suicide charges amongst the 16 deaths and sadly discovered that there have been 4 suicides throughout the 24-month interval. The authors acknowledged that the suicides occurred within the TAU group solely.
Folks offered fewer instances to hospital for therapy of their repeat self-harm at 12 and 24 months, after receiving the temporary textual content message intervention.
Conclusions
Total, this examine exhibits {that a} temporary textual content message intervention may scale back the variety of instances that folks return to hospital for therapy of repeat self-harm. The authors additionally state that “the 22% discount in repetition of hospital-treated self-harm was clinically significant” (Stevens et al., 2024, p. 106). This is a crucial discovering, given how simply implementable such an intervention may very well be, as it’s temporary and automatic. Nevertheless, the authors argue that it’s doubtless that extra research are wanted to ascertain additional efficacy and financial feasibility of the SMS intervention.
The intervention helped to cut back repeat self-harm re-presentations to hospital, however additional analysis is required to make sure its efficacy and affordability.
Strengths and limitations
The RCT, by Stevens et al., (2024), was the primary to discover a short SMS intervention in a inhabitants past a slender demographic. By exploring a wider inhabitants, this examine offered proof that the intervention may have efficacy in hospital settings, the place a big proportion of the inhabitants search self-harm therapy. As this was an RCT, the examine was randomised, which is one other energy, as this helps to enhance inside validity. It was additionally good to see that messages included within the intervention had been created by folks with lived psychological well being expertise, doubtless enhancing their appropriateness.
Nevertheless, the examine used non-standardised TAU situation. Though this may very well be argued as extra correct, as there may be variability in scientific settings, it may confound outcomes. Witt et al. (2018) state that non-standard TAU is a major supply of heterogeneity in research that examine self-harm interventions, and it’s crucial to have readability relating to what constitutes TAU. Though the authors did element what TAU was prone to encompass, they acknowledged that it diversified, which may have influenced outcomes. For instance, if one participant acquired a care plan that didn’t embrace psychological therapies, in comparison with one other participant that did obtain psychological therapies, this might have precipitated confounding variables.
One other fundamental limitation was the single-consent Zelen design. Though the Zelen design can enhance drop-out charges, as individuals could also be happier to be allotted to the therapy situation (Homer, 2002), the single-consent Zelen design requested for consent within the therapy group solely, which the authors state led to elevated attrition charges, which may have led to attrition bias. Individuals within the therapy situation had been additionally conscious of their allocation, which may have altered participant behaviour, finally impacting the validity of the examine. Moreover, the examine didn’t clarify whether or not the researchers had been blinded, so this will have additional impacted the findings.
Though an attention-grabbing addition to analysis, the examine has left some issues and questions relating to validity.
Implications for observe
Self-harm is a major burden on the wellbeing of the Australian inhabitants (Australian Institute of Well being and Welfare, 2019), subsequently the implications of the discount in repeat self-harm occasion charges are vital for sufferers, companies and practitioners.
Qualitative analysis has demonstrated that temporary SMS interventions could also be useful to people who find themselves self-harming by fostering a way of feeling supported by way of caring messages, and details about companies, if pressing psychological well being assist is required (Duan et al., 2020). This method to affected person aftercare subsequently could scale back demand on stretched Australian emergency departments (Australian Institute of Well being and Welfare, 2023), as messages encourage sufferers to make use of assist helplines for preventative self-harm care. Nevertheless, previous to implementation, additional analysis should discover why sufferers are re-presenting much less, and whether or not disaster strains, or supportive messages, are an informal mechanism by which re-presentation charges are decreased. Understanding the precise informal mechanisms will guarantee interventions are efficacious, ease demand, and obtain the very best outcomes when it comes to self-harm discount.
Because the UK experiences the identical difficulties as Australia, like excessive demand for pressing companies (Pines et al., 2011), and will increase in self-harm (McManus et al., 2016), the identical implications apply. Because the NHS strikes in direction of offering Enhanced Main Care Providers, which embrace psychological well being companies for folks with extra advanced displays, such an intervention could supply practitioners an simply implementable instrument which may assist scale back escalation to secondary care and enhance psychological well being literacy; each outcomes have the potential to boost affected person security and expertise in main care, particularly for extra at-risk sufferers. Additional analysis is required to discover an SMS intervention in main care settings to find out the efficacy of the intervention.
Lastly, the cost-effectiveness of the intervention should be examined. There’s proof to counsel that digital well being interventions could be cost-effective (Gentili et al., 2022), which may make an SMS intervention possible within the NHS, with out including vital monetary burden. Within the Speaking Therapies service that I work inside, the service has a longtime automated SMS service, which could be the case throughout different companies, so it may very well be simply implementable with little further sources.
Total, a short SMS intervention may very well be carried out inside psychological well being companies to cut back burden on pressing companies and enhance the wellbeing of the recipients, nonetheless, extra analysis is required relating to mechanisms of change, generalisability and financial viability earlier than adoption.
Additional analysis ought to discover the cost-effectiveness of the intervention, to assist the viability.
Assertion of pursuits
No conflicts of curiosity to declare.
Hyperlinks
Main paper
Stevens, G. J., Sperandei, S., Carter, G. L., Munasinghe, S., Hammond, T. E., Gunja, N., de la Riva, A., Brakoulias, V., & Web page, A. (2024). Efficacy of a brief message service temporary contact intervention (SMS-SOS) in decreasing repetition of hospital-treated self-harm: randomised managed trial. The British Journal of Psychiatry, 224(3), 106–113. https://doi.org/10.1192/bjp.2023.152
Different references
Australian Institute of Well being and Welfare. (2019). The well being impression of suicide and self-inflicted accidents in Australia. https://www.aihw.gov.au/stories/burden-of-disease/health-impact-suicide-self-inflicted-injuries-2019/contents/about
Australian Institute of Well being and Welfare. (2023). Emergency division care. https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care
Bhui, Okay., McKenzie, Okay., & Rasul, F. (2007). Charges, danger components & strategies of self hurt amongst minority ethnic teams within the UK: a scientific evaluate. BMC Public Well being, 7(1), 336. https://doi.org/10.1186/1471-2458-7-336
Duan, S., Wang, H., Wilson, A., Qiu, J., Chen, G., He, Y., Wang, Y., Ou, J., & Chen, R. (2020). Creating a Textual content Messaging Intervention to Cut back Deliberate Self-Hurt in Chinese language Adolescents: Qualitative Examine. JMIR MHealth and UHealth, 8(6), e16963. https://doi.org/10.2196/16963
Gentili, A., Failla, G., Melnyk, A., Puleo, V., Tanna, G. L. Di, Ricciardi, W., & Cascini, F. (2022). The price-effectiveness of digital well being interventions: A scientific evaluate of the literature. Frontiers in Public Well being, 10. https://doi.org/10.3389/fpubh.2022.787135
Geulayov, G., Casey, D., Bale, E., Model, F., Clements, C., Farooq, B., Kapur, N., Ness, J., Waters, Okay., Patel, A., & Hawton, Okay. (2022). Socio-economic disparities in sufferers who current to hospital for self-harm: sufferers’ traits and issues within the Multicentre Examine of Self-harm in England. Journal of Affective Issues, 318, 238–245. https://doi.org/10.1016/j.jad.2022.08.106
Geulayov, G., Casey, D., Bale, L., Model, F., Clements, C., Farooq, B., Kapur, N., Ness, J., Waters, Okay., Tsiachristas, A., & Hawton, Okay. (2019). Suicide following presentation to hospital for non-fatal self-harm within the Multicentre Examine of Self-harm: a long-term follow-up examine. The Lancet Psychiatry, 6(12), 1021–1030. https://doi.org/10.1016/S2215-0366(19)30402-X
Homer, C. S. E. (2002). Utilizing the Zelen design in randomized managed trials: debates and controversies. Journal of Superior Nursing, 38(2), 200–207. https://doi.org/10.1046/j.1365-2648.2002.02164.x
Liu, R. T., Sheehan, A. E., Walsh, R. F. L., Sanzari, C. M., Cheek, S. M., & Hernandez, E. M. (2019). Prevalence and correlates of non-suicidal self-injury amongst lesbian, homosexual, bisexual, and transgender people: A scientific evaluate and meta-analysis. Medical Psychology Evaluate, 74, 101783. https://doi.org/10.1016/j.cpr.2019.101783
McManus, S., Bebbington, P., Jenkins, R., & Brugha, T. (2016). Psychological Well being and Wellbeing in England: the Grownup Psychiatric Morbidity Survey 2014. https://openaccess.metropolis.ac.uk/id/eprint/23646/1/
Nationwide Institute for Well being and Care Excellence. (2022). Self-harm: evaluation, administration and stopping recurrence NICE guideline [NG225]. https://www.good.org.uk/steerage/ng225
Pines, J. M., Hilton, J. A., Weber, E. J., Alkemade, A. J., Al Shabanah, H., Anderson, P. D., Bernhard, M., Bertini, A., Gries, A., Ferrandiz, S., Kumar, V. A., Harjola, V.-P., Hogan, B., Madsen, B., Mason, S., Öhlén, G., Rainer, T., Rathlev, N., Revue, E., … Schull, M. J. (2011). Worldwide Views on Emergency Division Crowding. Tutorial Emergency Medication, 18(12), 1358–1370. https://doi.org/10.1111/j.1553-2712.2011.01235.x
Witt, Okay., de Moraes, D. P., Salisbury, T. T., Arensman, E., Gunnell, D., Hazell, P., Townsend, E., van Heeringen, Okay., & Hawton, Okay. (2018). Therapy as standard (TAU) as a management situation in trials of cognitive behavioural-based psychotherapy for self-harm: Affect of content material and high quality on outcomes in a scientific evaluate. Journal of Affective Issues, 235, 434–447. https://doi.org/10.1016/j.jad.2018.04.025
Zelen, M. (1979). A New Design for Randomized Medical Trials. New England Journal of Medication, 300(22), 1242–1245. https://doi.org/10.1056/NEJM197905313002203
