Week 4: Summary and discussion points

The paper chosen for discussion in #PHTwitJC on Sunday 9th October (8.00 pm GMT+1) is Green et al (2011) Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation.  The paper is available here.

What is self-harm?

NICE  define self-harm as “intentional self-poisoning or injury, irrespective of the apparent purpose of the act”. Self-harm therefore includes poisoning, asphyxiation, cutting, burning and other self-inflicted injuries.

Self-harm is a public health concern

Self harm is a major public health problem in many countries but uncertainty remains about which forms of treatment are most effective. In 2006 a national enquiry was led in the UK by the Mental Health Foundation and Camelot Foundation (click here to read more). Their findings included:

  • 1 in 15 young people (aged 11 to 25) were harming themselves deliberately.
  • In 2006/07 intentional self-harm was one of the top five external causes of admissions to acute hospital services for males and females of all ages in the UK – the majority of these cases involved self-poisoning.
  • Self-harming seems to be more prevalent in older groups: a study by Meltzer et al (2001), based on parental reports, suggests that the rate among 13-to 15-year-olds is one-and-a-half times that of 11-to 12-year-olds (2.5 and 1.6 per cent, respectively).
  • Self-harming is more prevalent in females than in males
  • “It is important to recognise that self-harm is not usually triggered by one isolated event but rather a set of circumstances that leave young people overwhelmed and unable to manage their feelings: it is not the core problem but a sign and symptom of underlying emotional difficulties, used as a way of coping.”

Summary of this week’s paper

This paper aimed to examine the effectiveness and cost-effectiveness of group therapy for self harm in young people (aged 12-17 years with at least two past episodes of self-harm) in 8 child and adolescent mental health services in the northwest UK.

Those randomised as ‘cases’ (n=183) received a programme of group therapy (6 weekly sessions) specifically designed for adolescents who harm themselves, followed by a booster phase of weekly groups as long as needed. Those randomised as ‘controls’ (n=183) were provided with “standard routine care according to clinical judgment” excluding any group interventions.

Intervention effectiveness was assessed by subsequent repeated episodes of self harm.  Other measures included severity of subsequent self harm, mood
disorder, suicidal ideation, and global functioning.  Intervention cost-effectiveness was assessed by recording the total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses.

Both cases and controls showed significant improvement from baseline to follow-up. Results states that at one year, those those who were exposed to the group therapy (cases) were less likely (odd ratio = 0.88 (0.59 to 1.33, P=0.52)) to repeat self-harm compared to the control group.  For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to1.20, P=0.29) at 6 months and 0.94 (0.63 to 1.40, P=0.75) at 1 year.  Total 1 year costs were higher in the group therapy arm (£21 781) than for routine care (£15 372) but the difference was reported to be not significant (95% CI −1416 to 10782, P=0.132).

The authors concluded:

The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations.

‘Live’ Public Health Twitter Journal Club will take place on Sunday 9th October, between 20:00 and 21:00 UK time (GMT+1). To follow and contribute to the discussion, remember to use the #PHTwitJC hashtag

The discussion points for this week are as follows:

  1. Were the aims of the study clearly defined?
  2. Was a randomised-control trial appropriate to answer this research question?  Was it ethical?
  3. The results were statistically insignificant.  Could anything else explain these disappointing results? (e.g. chance, bias, confounding, truth)
  4. What are the implications of the study for public health practice?
  5. “Self harm in adolescence remains a very challenging public health problem that deserves continuing research and clinical efforts towards its alleviation.” – what future research could help address self-harm in adolescence?
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One Response to Week 4: Summary and discussion points

  1. amcunningham says:

    We need to rethink the place of RCTs in complex interventions such as this. For a good discussion of the limits of RCTs in educational research see Norman: http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2923.2003.01586.x/abstract
    He wrote that in 2003. And he is no post-modernist. Now see this account calling for a moratorium on RCTs in this kind of health services research for the next 10 years:
    http://www.ncbi.nlm.nih.gov/pubmed/21565657
    It’s a provocative read.
    The problem is that even when an RCT is shown to work in one place (eg dementia care package in the Netherlands doesn’t show any benefit in Germany, but a process evaluation alongside may show why http://bmjopen.bmj.com/content/1/1/e000094.short)
    I look forward to seeing the transcript afterwards.
    AM

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