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QUESTION: In patients who have deliberately poisoned themselves, does brief psychodynamic interpersonal treatment (PIT) reduce suicidal ideation, severity of depression, and further episodes of self harm, and increase patient satisfaction?
A university hospital emergency department in Manchester, UK.
119 adults who were 18 to 65 years of age (mean age 31 y, 55% women), presented with an episode of deliberate self poisoning, were registered with a general practitioner and did not need inpatient psychiatric treatment. Follow up was 80%.
After stratification by history of self harm, patients were allocated to four 50 minute sessions of PIT (n=58) or to usual care (n=61). PIT consisted of identifying and helping to resolve interpersonal difficulties that caused or exacerbated psychological distress. The treatment was described in a standardised manual.
Main outcome measures
Suicidal ideation (Beck Scale for Suicidal Ideation). Secondary outcomes were depression symptoms (Beck Depression Inventory), patient satisfaction (10 point scale, higher scores indicate higher satisfaction), and further episodes of deliberate self harm.
Analysis was by intention to treat. After adjustment for baseline values, psychotherapy led to less suicidal ideation (p < 0.005) and less severe depression (p=0.037) than did usual care (table). The difference in depression scores was no longer statistically significant after adjustment for marital status. Patient satisfaction was higher for psychotherapy than for usual care (p=0.015) (table). Unadjusted rates for repeated selfharm were lower for psychotherapy than for usual care (p=0.009) (table).
In adults who have deliberately poisoned themselves, 4 sessions of psychodynamic interpersonal treatment reduced suicidal ideation and deliberate self harm and increased patient satisfaction.
Rates of hospital attendance after self harm are about 400 in 100 000 per year in the UK, and in people who have committed suicide 1 in 4 attended the hospital after a non-fatal act in the previous year. Under the circumstances, the evidence for the effectiveness of interventions is disappointing.1
Guthrie et al struggled with some familiar problems and, despite their best efforts, many exclusions and refusals of patients occurred; in the end, they included only 23% of presenting patients. We cannot be sure how generalisable their findings are, although patient baseline characteristics were typical for the UK.
Final numbers were respectable but were nonetheless relatively small and possibilities exist for bias. For example, the treatment and control groups differed in marital status and previous psychiatric history. The authors adjusted for some potential confounders in their analysis but not for all. The apparently large effect of psychological treatment on the repeated self harm rate needs to be viewed with caution.
The results of this trial are encouraging because they add to the evidence that brief psychological treatments improve outcomes after self harm.2 Those who are sympathetic will accept the study findings as further evidence that patients with such a high burden of problems and risk for suicide should be offered treatment. Promising treatments (like the one evaluated here) are brief, have a strong focus on practical problem solving and interpersonal difficulties, and are delivered in a format that patients find acceptable.
For the sceptical, the evidence remains less than rock solid. We still need large multicentre trials to test the real-world effectiveness of psychological treatments before we can argue for their routine inclusion in clinical services.
Web extra material
The intervention group received psychotherapy that was based on a model developed by Hobson. The therapy is described in a standardised manual, and involves identifying and helping to resolve interpersonal difficulties that cause or exacerbate psychological distress. Therapy was delivered by nurse therapists in the patients� homes. 4 weekly 50 minute sessions were offered. Treatment fidelity and adherence was ensured by weekly supervision, audiotaping of interviews, and use of a standardised rating scale.
The control group received usual care, which consists of an assessment by a casualty doctor or junior psychiatrist in the emergency department. Approximately one third of patients are routinely referred for follow up as a psychiatry outpatient, a few are referred to addiction services, and the rest are advised to consult their own general practitioner. No patients are routinely referred to psychotherapy or psychology services.
1 Hobson RF. Forms of feeling: the heart of psychotherapy. London: Tavistock Publications, 1985.
2 Shapiro DA, Startup MJ. Raters� manual for the Sheffield psychotherapy rating scale. Sheffield: MRC/ESRC Social and Applied Psychology Unit, University of Sheffield, 1990.
The manual cited in reference 2 is available from:
The Psychological Therapies Research Centre
School of Psychology
University of Leeds
17 Blenheim Terrace
Leeds LS2 9JT, UK
E-mail Fax +44 (0) 113 233 1956
Sources of funding: North West Regional Health Authority and NHS Research and Development Levy.
For correspondence: Dr E Guthrie, School of Psychiatry and Behavioural Sciences, University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Manchester M13 9WL, UK. Fax +44 161 273 2135.
Abstract and commentary also appear in Evidence-Based Mental Health.
↵† Information provided by author.
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