Cognitive-behavioural problem solving in the treatment of patients who repeatedly attempt suicide. A controlled trial. Intensive in-patient and community intervention versus routine care after attempted suicide. A randomised controlled intervention study. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Evaluation of a social work service for self-poisoning patients. Cost-effectiveness analysis of a home-based social work intervention for children and adolescents who have deliberately poisoned themselves. Results of a randomised controlled trial. General hospital admission in the management of parasuicide. A randomised controlled trial. Evaluation of out-patient counselling compared with general practitioner care following overdoses. Domiciliary and out-patient treatment of self-poisoning patients by medical and non-medical staff. Secondary prevention of non-fatal deliberate self-harm. The green card study. Reduction by paroxetine of suicidal behavior in patients with repeated suicide attempts but not major depression. Behavior therapy vs insight-oriented therapy for repeated suicide attempters. Interpersonal problem-solving skills training in the treatment of self-poisoning patients. The management of non-compliance with referral to out-patient after-care among attempted suicide patients: a controlled intervention study. A follow-up program for suicide attempters: evaluation of effectiveness. Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm.
In a controlled trial, 20 patients at high risk of repeated suicide attempts were randomly allocated to either cognitive-behavioural problem solving or a 'treatment-as-usual' control condition. The group practising problem solving improved significantly more than controls on ratings of depression, hopelessness, suicidal ideation and target problems at the end of treatment and at follow-up of up to one year, and there was evidence of an effect on the rates of repetition over the six months after treatment. A randomised clinical trial was carried out in suicide attempters to assess clinical efficacy of an intensive psychosocial intervention compared with treatment as usual.
                Two hundred and seventy-four suicide attempters presenting for medical treatment were randomly assigned to either intensive psychosocial treatment or 'care as usual'. Intensive psychosocial treatment consisted of brief admission to a special crisis-intervention unit and problem-solving aftercare. 'Care as usual' included any form of treatment the assessing clinicians thought appropriate. Psychological well-being was evaluated by the SCL-90 and the Hopelessness Scale at 3, 6 and 12 months following entry in the study.
                No differences in outcome were found. The probability of repeat suicide attempts in the 12-month follow-up was 0.17 for patients in the experimental group and 0.15 for the control group. There were no differences in ratings on the SCL-90 and the Hopelessness Scale. Patients in the experimental group attended significantly more out-patient treatment sessions.
                General implementation of an intensive in-patient and community intervention programme for suicide attempters does not seem justified. A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year. Four hundred patients aged at least 17 who came to Casualty in one year after deliberately poisoning themselves were randomly assigned between an Experimental social work service (task-centered casework) and a Control (routine) follow-up service. 139 patients were excluded from the trial, most of whom were already in continuing psychiatric treatment. After one year there was no difference in the proportions of E and C patients who repeated self-poisoning (about 14 per cent), but significantly more of the excluded group had repeated (36 per cent). A random half of the trial patients were re-interviewed four months after admission. Both E and C groups had improved to a significant extent on measures of depressed mood and of social problems. E patients showed more change in social problems and were more satisfied with the service they had received. Little evidence exists regarding the effectiveness or cost-effectiveness of alternative treatment services in the field of child and adolescent psychiatry.
                To assess the cost-effectiveness of a home-based social work intervention for young people who have deliberately poisoned themselves.
                Children aged < or = 16 years, referred to child mental health teams with a diagnosis of deliberate self-poisoning were randomly allocated to either routine care (n = 77) or routine care plus the social work intervention (n = 85). Clinical and resource-use data were assessed over six months from the date of trial entry.
                No significant differences were found between the two groups in terms of the main outcome measures or costs. In a sub-group of children without major depression, suicidal ideation was significantly lower in the intervention group at the six-month follow-up (P = 0.01), with no significant differences in cost.
                A family-based social work intervention for children and adolescents who have deliberately poisoned themselves is as cost-effective as routine care alone. Suitably trained junior doctors selected parasuicides with no immediate medical or psychiatric treatment needs on initial assessment in a casualty department. This group was then randomly allocated to hospital admission (38 cases) or discharge home (39 cases). One week later there were no significant differences between groups on diverse outcome measures, including repetition rate, psychological symptoms, and social functioning. A second follow-up using the same measures at 16 weeks also failed to demonstrate any differences between groups, both of which showed considerable overall improvement. A parasuicide management policy consisting of assessment in a casualty department and selective discharge was appropriate for 15% of a hospital-referred population. This lends support to recent government recommendations, but caution should be exercised before such a result is generalised. In a randomized prospective treatment study, 80 overdose patients (not requiring intensive psychiatric intervention) received either brief out-patient counselling or were returned to the care of their general practitioners with advice on management. There was little difference in outcome between the two groups. However, two sub-groups of patients benefited more from out-patient counselling than from general practitioner care, these were: (a) women, and (b) patients with dyadic problems. Counselling following overdoses should be focused on groups of patients such as these who are most likely to benefit from it. Further work is needed to identify treatment approaches that will help other groups who take overdoses, especially men. In a study of domiciliary and out-patient treatment of self-poisoning patients, using a brief problem-orientated approach, it was found that domiciliary treatment resulted in much higher attendance rates but no difference in outcome. Patients who completed out-patient treatment had a better outcome than those who failed to attend treatment sessions. Completion of out-patient treatment was more frequent among higher social class patients. Domiciliary treatment may be more appropriate in some cases for married patients and for those of lower social class. Medical and non-medical staff proved to be equally effective therapists. Future research should be concerned with evaluation of alternative methods of provision of help and further identification of patients who are most likely to benefit from treatment. In an attempt to address the low compliance with offers of treatment shown by patients after episodes of non-fatal deliberate self-harm (DSH), patients who had harmed themselves for the first time were offered rapid, easy access to on-call trainee psychiatrists in the event of further difficulties, and they were encouraged to seek help at an early stage should such problems arise. The follow-up data obtained after one year showed a significant reduction of actual or seriously threatened DSH in the experimental group, who also made considerably less demands on medical and psychiatric services, when compared with controls. Suicidal behavior has been associated with reduced central serotonergic function. Because selective serotonin reuptake inhibitors (SSRIs) enhance serotonergic function, the authors studied the efficacy of an SSRI, paroxetine, in the prevention of recurrent suicidal behavior.
                They conducted a 1-year double-blind study comparing paroxetine (40 mg/day) and placebo in 91 patients who had recently attempted suicide for at least a second time. None of the patients had experienced a major depressive episode or had any other major DSM-III-R axis I diagnoses. At least one cluster B personality disorder was present in 74 patients.
                With adjustment for the number of previous suicide attempts, paroxetine showed significant efficacy in the prevention of recurrent suicidal behavior. Among the patients who had attempted suicide fewer than five times, 12 (36%) in the placebo group (N = 33) and five (17%) in the paroxetine group (N = 30) made a subsequent suicide attempt. Paroxetine was also significantly more effective in patients who met fewer than 15 criteria for cluster B personality disorders than in those who met more than 15 criteria. Overall, paroxetine was not significantly different from placebo in its effect on depressive mood, hopelessness, and anger. However, the data suggest that paroxetine may have some temporary effect in reducing anger.
                This study indicates that enhancing serotonergic function with an SSRI may reduce suicidal behavior in a subgroup of patients who have attempted suicide more than once but who do not suffer from major depression. A behavior therapy package was compared with insight-oriented therapy in a clinical trial for repeated suicide attempters. Self-report measures of depression, anxiety, and assertiveness were obtained before and after ten days of inpatient treatment and at follow-up intervals for nine moths. Interviews with patients during a two-year follow-up period elicited frequency of suicidal attempts and ideation. Results indicated the superiority of the behavior therapy package, with the structured, brief hospitalization and assertive follow-up likely contributing to the main effects. The present study evaluated the effectiveness of interpersonal problem-solving skills training (IPSST) for the treatment of self-poisoning patients. Thirty-nine self-poisoning patients were assigned randomly either to IPSST or to a control treatment condition (a brief problem-oriented approach). Both conditions were equally effective in reducing the number of presenting problems and in reducing hopelessness levels. However, the IPSST condition was significantly more effective than the control condition as determined by other outcome measures (measures of interpersonal cognitive problem solving, self-rated personal problem-solving ability, perceived ability to cope with ongoing problems, and self-perception). Follow-up studies showed maintenance of IPSST treatment gains at 6 months and a greater reduction of repetition of self-poisoning in the IPSST group at 1 year posttreatment. The failure to comply with referral for out-patient after-care is a well-documented problem among attempted suicide patients. The present study aimed at the investigation of an experimental referral procedure by means of a randomized controlled study. Non-compliant patients in the experimental group were visited in their homes by a community nurse in order to assess reasons for non-compliance and to motivate patients to comply with referral. One year after their suicide attempt patients were visited in their homes in order to assess repetition of suicidal behaviour. Uni- and multi-variate analyses showed a significant beneficial effect of the experimental procedure on compliance with referral. A near-significant effect of the experimental procedure on the rate of repetition of suicidal behaviour was found. Suicide attempters are a high-risk group in relation to ultimately completing suicide and are usually "treated and released" with little or no follow-up care. A 4-month follow-up outreach program for suicide attempters seen in the emergency room was developed with an emphasis on continuity and quantity of "treatment" received. Suicide attempters were randomly assigned to the "follow-up outreach" or "normal" treatment programs. Measures for the evaluation of effectiveness were (a) incidence of suicide reattempts and purposive accidents and (b) prevalence of drug misuse and excessive use of alcohol. The experimental group showed a statistically significant reduction in suicide reattempts and excessive use of alcohol, while the reduction of drug abuse, although not statistically significant, did conform to a trend indicating improvement. Purposive accidents occured at a relatively equal rate among both groups. The treatment of deliberate self-harm (parasuicide) remains limited in efficacy. Despite a range of psychosocial, educational and pharmacological interventions only one approach, dialectical behaviour therapy, a form of cognitive-behaviour therapy (CBT), has been shown to reduce repeat episodes, but this is lengthy and intensive and difficult to extrapolate to busy clinical practice. We investigated the effectiveness of a new manual-based treatment varying from bibliotherapy (six self-help booklets) alone to six sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behaviour therapy.
                Thirty-four patients, aged between 16 and 50, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with manual-assisted cognitive-behaviour therapy (MACT N = 18) or treatment as usual (TAU N = 16). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined.
                Thirty-two patients (18 MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0.17/month MACT; 0.37/month TAU; P = 0.11) and self-rated depressive symptoms also improved (P = 0.03). The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with MACT (P = 0.22).
                Although limited by the small sample, the results of this pilot study suggest that this new form of cognitive-behaviour therapy is promising in its efficacy and feasible in clinical practice.
There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.