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Review: problem solving treatment after deliberate self harm improves depression, hopelessness, and personal problems
  1. Simon Hatcher, BSc, MBBS, MMedSc
  1. University of Auckland, Auckland, New Zealand

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 QUESTION: In people committing deliberate self harm, does problem solving treatment improve mood, hopelessness, and personal problems?

    Data sources

    Studies were identified by searching Medline; EMBASE/Excerpta Medica; PsycLIT; the Cochrane Controlled Trials Register; and the Cochrane Depression, Anxiety, and Neurosis Trials Register; and by hand searching journals.

    Study selection

    2 reviewers independently selected studies if they were randomised controlled trials that compared problem-solving treatment with any control intervention for deliberate self harm. Studies were excluded if participants were suicide ideators (without self harm) or if deliberate self harm was an outcome variable in people with depression (without previous self harm).

    Data extraction

    2 reviewers independently extracted data on patient and trial characteristics and outcomes (depression, hopelessness, and improvement in problems). Disagreements were resolved by a third reviewer.

    Main results

    6 studies met the selection criteria. Sample sizes ranged from 10 to 400 patients (mean 97 patients). Control treatments were usual care (2 studies), individual psychological treatment (1 study), general practitioner care (1 study), standard psychiatric treatment (1 study), and brief problem solving treatment, which was standard aftercare focusing on solving the immediate problem rather than providing skills to improve problem solving ability (1 study). 4 studies reported depression outcomes (3 used the Beck Depression Inventory; 1 used the Hospital Anxiety and Depression Scale) and showed that problem solving treatment was more effective than control treatments for relieving depression (p=0.04) (table). 3 studies assessed hopelessness by using the Hopelessness Scale. The pooled results showed that patients in the problem solving group had less hopelessness than did patients in the control group (p=0.002) (table). 2 studies showed that more patients in the problem solving group than in the control group had improvement in their problems (p=0.004) (table).

    Problem solving treatment v control treatment for deliberate self harm*


    In patients committing deliberate self harm, problem solving treatment improves depression, hopelessness, and personal problems.

 QUESTION: In people committing deliberate self harm, does problem solving treatment improve mood, hopelessness, and personal problems?


    Patients who present to general hospitals after deliberately harming themselves are a common problem. It is somewhat embarrassing that we still do not have good evidence to determine the best treatment for this group in the era of evidence-based medicine. As one author of the review by Townsend et al pointed out in an earlier article,1 previous treatment trials have not been large enough to stand a good chance of detecting a statistically significant difference when repetition of deliberate self harm is the outcome. Although repetition is important, most people do not repeat, and other outcomes are also important. This review considers the effect of problem solving treatments on depression, hopelessness, and improvement in problems. Reassuringly, as seen from the limited evidence available, problem solving treatment seems to improve these outcomes.

    Two problems arise in interpreting the evidence. First, patients who agree to be randomised in these trials probably differ from most people who harm themselves. Many trials done in the area of self harm exclude large numbers of people who refuse to be randomised or who do not meet the study criteria (those with substance abuse are often excluded). Second, both the problem solving treatments and the control interventions varied among the included studies. Although these problems do not invalidate the findings in this review, they may affect their generalisability.

    A large study using problem solving treatment with repetition and other relevant outcomes is clearly needed. A key question for hard-pressed clinical services and funders is the minimum amount of treatment needed to make a difference. For clinicians and patients, problem solving treatment appears to be the most appealing and pragmatic treatment available that has evidence to show it improves some important outcomes after deliberate self harm.


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    • Sources of funding: South East Region NHSE Research and Development Committee and the former Anglia and Oxford NHSE Research and Development Committee.

    • For correspondence: Professor K Hawton, University of Oxford, Oxford, UK. keith.hawton{at}

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      Additional information can be found on the Evidence-Based Medicine website