Electronic Letters to:
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eLetters: Electronic letters published:
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CBT for Self-Harm: Conclusions Overstated??
- Dr Mukesh Kripalani, Dr. Amanda Gash, Prof. Joe Reilly (9 April 2008)
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CBT for Self-Harm: No Overstated Conclusions
- Philip Spinhoven, Ella Arensman (15 April 2008)
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Dr Mukesh Kripalani, Specialist Registrar Northern Deanery, Dr. Amanda Gash, Prof. Joe Reilly
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drmukesh{at}doctors.org.uk Dr Mukesh Kripalani, et al.
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We read Nadjee et al’s article in the March 2008 edition of the BJP (http://bjp.rcpsych.org/cgi/content/full/192/3/202) with interest and concern. We believe there are major biases towards the treatment arm of this study which may invalidate their conclusions. Furthermore, our experience of working in a liaison psychiatry team receiving more than 1500 self-harm referrals a year leads to question the applicability of the intervention given the characteristics of the study group. At the outset, there are more subjects in the TAU group shown to be depressed in the TAU group and this difference reaches statistical significance from the first follow-up at 3 months and the difference gradually grows with each follow-up. Hence it can be argued that the difference in outcome is a mere difference in depression and anxiety, which we know responds well to CBT. Moreover, as the authors themselves admit, there was a trend from the beginning of higher suicidal cognitions in the TAU group, which assumed statistical significance from the first follow-up at 3 months. Furthermore, the authors have not attempted to match the extra time spent with subjects in the CBT group with a similar amount of therapist/contact time in the TAU. Masking (as acknowledged) of follow-up assessments was not undertaken. Therapists in the treatment group very actively pursued participants; this may have been the active ingredient rather than CBT. Sending postcards alone as an intervention significantly reduces the frequency of hospital treated self-poisoning events (1). All these factors bias the results in favour of the treatment group. Despite these biases, the reported benefit in reducing self harm was marginal and only statistically significant at 9 months, with questionable clinical significance. The participants in this study differ very significantly from the individuals seen after self-harm by routine liaison psychiatry services. The self harm definition used was very wide, including punching and head banging, which are not usually defined as self-harm by clinicians, and not proven to be associated with higher suicide risk, unlike self-poisoning and self-cutting. No data is reported on the proportion of self-harm in the study which was of this milder nature. Right from the recruitment phase, participants with alcohol and drug misuse were eliminated. This clearly skews the population enormously since a very high proportion of our patients have co-morbid issues. The treatment group in particular lost eight individuals before CBT was started, and all assessments and therapy sessions were then completed. We contend that this was a highly motivated and selected group likely to benefit from the intervention, and unrepresentative of the clinical population. Short-term interventions for self harm have not generally proved significant when explored in large scale studies (2). It is therefore crucial that small randomised trials of CBT or other interventions are carefully designed to minimise bias, and we feel this study fell short of the design and reporting standards we would expect. We are also concerned that high-profile publication of such studies may lead to unwarranted implementation of interventions whose effect is unproven, and whose opportunity costs are great. References: 1. Carter et al. Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning. The British Journal of Psychiatry (2007) 191: 548-553. doi: 10.1192/bjp.bp.107.038406 http://bjp.rcpsych.org/cgi/content/full/191/6/548 2. Crawford M.J, Kumar P. Intervention following deliberate self- harm: enough evidence to act? Evidence-Based Mental Health 2007;10:37-39 http://ebmh.bmj.com/cgi/content/full/10/2/37 Authors: Dr. Mukesh Kripalani, SpR, Northern Deanery Dr. Amanda Gash, Consultant Liaison Psychiatrist Prof. Joe Reilly, Clinical Director for R&D (Tees, Esk and Wear Valleys NHS Trust), Director, Mental Health Research Centre (Durham University), Deputy Lead (Mental Health Research Network North East Hub), Durham University Acknowledgements: Liaison Psychiatry Team based at Middlesborough, Tees, Esk and Wear Valley NHS Trust. |
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Philip Spinhoven, Professor of Clinical Psychology Leiden University, Ella Arensman
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spinhoven{at}fsw.leidenuniv.nl Philip Spinhoven, et al.
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Authors’reply: Kripalani et al. express their concerns about biases towards the treatment arm of our study and the characteristics of our study group of deliberate self-harm (DSH) patients. With respect to biases towards the treatment arm, it should be noted that at the start of treatment no significant differences in anxiety, depression and suicidal cognitions were evident and that the gradually growing difference in depression and suicidal cognitions from the first follow-up at 3 months and in anxiety at the 9 months follow-up in our opinion reflects a treatment effect. Just because the effects on secondary measures were stronger than on the target variable deliberate self-harm, we concluded that as hypothesized CBT primarily targeted maintaining factors of DSH and that the specific DSH effect was a secondary effect. Moreover, our study results remain silent on the question whether the treatment effects observed are attributable to specific ingredients of CBT or to the total package of CBT in addition to TAU. We agree with Kripalani et al. however that the fact that assessments were not carried out masked to treatment group might have influenced outcome. With respect to characteristics of the study group, participants in our study manifested both deliberate self-poisoning (91%) and deliberate self- injury (9%) irrespective of the apparent purpose of the act, and therefore can be considered a representative sample of DSH patients. Of the contacted participants only 7.3% were excluded because of schizophrenia or alcohol and drug misuse. Our final sample consisted of females (94%) with a long history of DSH (77% reported 10 or more previous episodes of self- poisoning and/or self-injury) and severe psychological and psychiatric problems (on average four psychiatric diagnoses (mood and anxiety disorders in particular)). It is possible that CBT as an add-on to TAU is more likely to be effective in such a chronic and severe DSH group. The fact that rate of withdrawal from CBT amounted to 17% underscores the feasibility of an intervention tailored to the needs of this particular target group. In conclusion, CBT appears to be an effective adjunct to TAU in chronic DSH and further research in moderators and mediators of change seems warranted. |
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