A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: A randomised controlled trial

Background. We investigated for the first time whether a volitional helpsheet (VHS), a brief psychological intervention, reduced repeat self-harm in the six months following a suicide attempt.

Methods. We conducted a prospective, single site, randomised controlled trial. Patients admitted to hospital after a suicide attempt were randomly assigned (1:1), via web-based randomization to receive either treatment as usual (control) or the VHS plus treatment as usual (intervention). Randomisation was stratified by sex and self-reported past self-harm history. There were three primary outcomes: (i) the number of participants who re-presented to hospital with self-harm over six months; (ii) the number of re-presentations and; (iii) cost effectiveness of the VHS. Follow-up data collection was via data linkage and patient medical records. We conducted intention to treat (ITT) and per protocol (PP) analyses. The trial is registered with ISRCTN, number 99488269.

Findings. Between 9th May 2012 and 24th February 2014, 518 patients were randomized to intervention (n=259) or control groups (n=259). We obtained complete follow-up data on 98•8% (512/518). 11 patients did not complete the VHS. Overall, the intervention did not affect the number of people who presented with self-harm (OR=0.90, 95% CI = 0.58-1.39, p= 0.63). However, PP sub-group analyses yielded a non-significant trend of treatment leading to a decreased proportion of participants re-presenting overall among those with a history of self-harm (difference in re-presentation=8.6%, 95% CI=-1.34 to 18.54, p=0•087). In terms of number needed to treat, 1 in every 12 patients treated should show benefit. However, for those with no history of self-harm hospitalisation, although there was no significant effect of treatment, 1 in 13 may be harmed (re-present with self-harm). The intervention had no effect on the number of re-presentations; however, in the PP sub-group analyses, among those who had been previously hospitalised with self-harm, there was a 69% reduction in the frequency of re-presentation to the Emergency Department (IRR = 0•31, 95% CI= 0•14 to 0•71, p= 0.0050) and a 55% reduction in the total number of re-presentations (total: IRR=0•45, 0•26-0.77, p=0•0040). In the ITT analyses, this reduction did not reach statistical significance.

Interpretation. Although the VHS had no overall effect, it may be effective in reducing self-harm among those who attempt suicide and have a history of self-harm hospitalisation.