Division of Psychiatry, University of Bristol
Department of Psychotherapy, Gaskell House, Manchester
University of Bristol, Cotham House, Bristol;
Cedar House, Blackberry Hill Hospital, Bristol
Department of Social Medicine, University of Bristol, Canynge Hall,
Bristol, UK
Correspondence: Dr J. Evans, Consultant Senior Lecturer, Division of Psychiatry, University of Bristol, Cotham House, Cotham Hill, Bristol BS6 6JL, UK. Tel: +44 (0)117 9546635; fax: +44 (0) 117 9546672; e-mail: j.evans j.evans{at}bristol.ac.uk
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ABSTRACT |
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INTRODUCTION |
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We report the results of the 12-month follow-up of the crisis card study. This allows direct comparison with other studies reporting 12-month repetition rates and further investigation of the potential benefit of this intervention for those who have no previous history of self-harm.
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METHOD |
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We identified repetition of self-harm by means of a self-harm case register (Evans et al, 1996). We used logistic regression in Stata version 8.0 for Windows to calculate odds ratios for repetition comparing control and intervention groups. We investigated whether the effect of the intervention differed between people with and without a previous history of self-harm by fitting an interaction term (treatment x past history) to our model and investigating the overall treatment effect. We compared time to episode of repeat self-harm between those receiving standard care and those with a crisis card using the log-rank test.
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RESULTS |
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Main analysis
There were 167 individuals (20.2%) with repeat episodes of self-harm in the
12 months after the index episode. Of participants carrying a crisis card, 90
(21.6%) had a repeat episode of self-harm within 1 year compared with 77
(18.8%) in the control group (OR=1.19, 95% CI 0.85-1.67). Time to repetition
did not differ between the control and intervention groups (log-rank test
2 0.98, P=0.32). The Kaplan-Meier curve is shown in
Fig. 1.
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During the first 6 months following the provision of the card, 70 individuals made telephone contact; the majority only once; the maximum number of contacts was 16. We have no data on subjects trying to make contact but failing to get past the hospital switchboard. There was no report of such difficulties. Of patients in the intervention group, those making telephone contact were more likely to have repeat episodes of self-harm (OR=4.91, 95% CI 2.83-8.50).
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DISCUSSION |
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A number of issues need consideration. We defined repetition by hospital attendance following self-harm. It is known that self-reported repetition rates are higher than those identified solely through hospital attendance (Guthrie et al, 2001). It is unlikely that this differed between intervention and control groups. Although this study was large, it was not large enough to exclude a clinically important effect in those presenting following a first episode. The 95% confidence intervals around the estimated effect of the intervention following a first episode included a 48% reduction and a 52% increase in repetition. As this intervention is likely to be much cheaper than manual-assisted cognitive therapy, a small beneficial effect may still be cost-effective.
This study was based on services running nearly 10 years ago. There have been major changes in mental health service provision in the UK in recent years (Department of Health, 1999). It is noteworthy that those who made contact were at greater risk of repetition, possibly because they had suicidal ideas. An alternative explanation is that the telephone contact evoked feelings of rejection thereby increasing risk. More skilled handling of those in crisis may be necessary. Crisis teams are now widely available and staffed 24 h a day. These teams include staff with specific training or experience in crisis management. It is possible that contact with crisis teams might prevent repeated self-harm more effectively than contact with on-call junior doctors as offered in this study. The context in which the card is provided is important. We did not have any information about how many subjects kept the card or whether they thought it might be useful. The card is more likely to be effective if the recipient is confident they can use it. Often specialist teams assess those presenting with an episode of self-harm; this includes crisis teams in some areas. Such teams might encourage greater confidence in the card as an alternative to self-harm.
Before conducting further trials of sufficient size, qualitative research should be undertaken to investigate whether this intervention might benefit those presenting following a first episode. This could help to refine the intervention to utilise some of the potentially beneficial changes in mental health service provision in the UK since the planning of this original trial.
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ACKNOWLEDGMENTS |
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REFERENCES |
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Department of Health (1999) A National Service Framework for Mental Health. London: Department of Health.
Evans, J., Johnson, C., Stanton, R., et al (1996) How to establish case registers: II. Non-fatal deliberate self-harm. Psychiatric Bulletin, 20, 403 -405.
Evans, M. O., Morgan, H. G., Hayward, A., et al (1999) Crisis telephone consultation for deliberate self-harm patients: effects on repetition. British Journal of Psychiatry, 175, 23 -27.[Abstract]
Guthrie, E., Kapur, N., Mackway-Jones, K., et al
(2001) Randomised controlled trial of brief psychological
intervention after deliberate self poisoning. BMJ,
323, 135
-138.
Hawton, K., Arensman, E., Townsend, E., et al
(1998) Deliberate self harm: systematic review of efficacy of
psychosocial and pharmacological treatments in preventing repetition.
BMJ, 317, 441
-447.
Tyrer, P., Thompson, S., Schmidt, U., et al (2003) Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychological Medicine, 33, 969 -976.[CrossRef][Medline]
Received for publication June 15, 2004. Revision received October 19, 2004. Accepted for publication October 21, 2004.