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 change into 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 many who determine 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). General, self-harm is a fancy and life-threatening phenomenon; one which warrants vital consideration.
The current examine, by Stevens and colleagues (2024), seeks to determine whether or not a quick textual content message intervention may assist in lowering the variety of occasions 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 the sort of intervention on a broader inhabitants in Australia. Earlier analysis has been centered on particular populations, like army personnel, due to this fact, this examine has the potential to contribute to the interventions’ generalisability to a wider group of individuals.
Strategies
Stevens et al., (2024) performed a parallel RCT which in contrast individuals who obtained therapy as normal (TAU), with individuals who obtained TAU, plus 9 transient 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 have been personalised with the individuals title, included an expression of concern for participant wellbeing, and included particulars of accessible native psychological well being providers and disaster traces. The messages have been developed by consultants with lived expertise.
As soon as enrolled, individuals have been stratified by first and subsequent self-harm presentation as there was vital variability amongst individuals. After stratification, individuals have 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 curiously 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 normal RCT, whereby individuals within the intervention group solely are requested to offer 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 important three main outcomes, and two secondary outcomes.
Main outcomes
- The variety of occasions that folks repeated self-harm, and wanted hospital therapy for this, diminished 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 individuals re-presenting for self-harm therapy within the SMS group.
- Females had greater charges of re-presentation for self-harm, however the impact of the transient 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 concerning 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 introduced to hospital with self-harm, to after they introduced 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 concerning 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 cut back the variety of occasions individuals 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 said that the suicides occurred within the TAU group solely.
Conclusions
General, this examine reveals {that a} transient textual content message intervention may cut back the variety of occasions 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 vital discovering, given how simply implementable such an intervention may very well be, as it’s transient and automatic. Nonetheless, the authors argue that it’s seemingly that extra research are wanted to ascertain additional efficacy and financial feasibility of the SMS intervention.
Strengths and limitations
The RCT, by Stevens et al., (2024), was the primary to discover a quick 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 inner validity. It was additionally good to see that messages included within the intervention have been created by individuals with lived psychological well being expertise, seemingly bettering their appropriateness.
Nonetheless, the examine used non-standardised TAU situation. Though this may very well be argued as extra correct, as there may be variability in medical settings, it may confound outcomes. Witt et al. (2018) state that non-standard TAU is a big supply of heterogeneity in research that examine self-harm interventions, and it’s crucial to have readability concerning what constitutes TAU. Though the authors did element what TAU was more likely to encompass, they said that it diverse, which may have influenced outcomes. For instance, if one participant obtained a care plan that didn’t embrace psychological therapies, in comparison with one other participant that did obtain psychological therapies, this might have induced confounding variables.
One other important 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. Members within the therapy situation have 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 have been blinded, so this will have additional impacted the findings.
Implications for observe
Self-harm is a big burden on the wellbeing of the Australian inhabitants (Australian Institute of Well being and Welfare, 2019), due to this fact the implications of the discount in repeat self-harm occasion charges are vital for sufferers, providers and practitioners.
Qualitative analysis has demonstrated that transient SMS interventions could also be useful to people who find themselves self-harming by fostering a way of feeling supported by means of caring messages, and details about providers, if pressing psychological well being help is required (Duan et al., 2020). This method to affected person aftercare due to this fact could cut back demand on stretched Australian emergency departments (Australian Institute of Well being and Welfare, 2023), as messages encourage sufferers to make use of help helplines for preventative self-harm care. Nonetheless, previous to implementation, additional analysis should discover why sufferers are re-presenting much less, and whether or not disaster traces, or supportive messages, are an informal mechanism by which re-presentation charges are diminished. 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 providers (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 Companies, which embrace psychological well being providers for individuals with extra advanced shows, such an intervention could supply practitioners an simply implementable device which may assist cut back escalation to secondary care and enhance psychological well being literacy; each outcomes have the potential to reinforce 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 have to be examined. There may be proof to recommend that digital well being interventions might 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 would be the case throughout different providers, so it may very well be simply implementable with little extra assets.
General, a quick SMS intervention may very well be applied inside psychological well being providers to scale back burden on pressing providers and enhance the wellbeing of the recipients, nevertheless, extra analysis is required concerning mechanisms of change, generalisability and financial viability earlier than adoption.
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 transient contact intervention (SMS-SOS) in lowering 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
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