Commentary

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.