A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial.

BACKGROUND: Self-harm in adolescents is common and repetition rates high. There is limited evidence of the effectiveness of interventions to reduce self-harm. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of family therapy (FT) compared with treatment as usual (TAU). DESIGN: A pragmatic, multicentre, individually randomised controlled trial of FT compared with TAU. Participants and therapists were aware of treatment allocation; researchers were blind to allocation. SETTING: Child and Adolescent Mental Health Services (CAMHS) across three English regions. PARTICIPANTS: Young people aged 11-17 years who had self-harmed at least twice presenting to CAMHS following self-harm. INTERVENTIONS: Eight hundred and thirty-two participants were randomised to manualised FT delivered by trained and supervised family therapists (n = 415) or to usual care offered by local CAMHS following self-harm (n = 417). MAIN OUTCOME MEASURES: Rates of repetition of self-harm leading to hospital attendance 18 months after randomisation. RESULTS: Out of 832 young people, 212 (26.6%) experienced a primary outcome event: 118 out of 415 (28.4%) randomised to FT and 103 out of 417 (24.7%) randomised to TAU. There was no evidence of a statistically significant difference in repetition rates between groups (the hazard ratio for FT compared with TAU was 1.14, 95% confidence interval 0.87 to 1.49; p = 0.3349). FT was not found to be cost-effective when compared with TAU in the base case and most sensitivity analyses. FT was dominated (less effective and more expensive) in the complete case. However, when young people's and caregivers' quality-adjusted life-year gains were combined, FT incurred higher costs and resulted in better health outcomes than TAU within the National Institute for Health and Care Excellence cost-effectiveness range. Significant interactions with treatment, indicating moderation, were detected for the unemotional subscale on the young person-reported Inventory of Callous-Unemotional Traits (p = 0.0104) and the affective involvement subscale on the caregiver-reported McMaster Family Assessment Device (p = 0.0338). Caregivers and young people in the FT arm reported a range of significantly better outcomes on the Strengths and Difficulties Questionnaire. Self-reported suicidal ideation was significantly lower in the FT arm at 12 months but the same in both groups at 18 months. No significant unexpected adverse events or side effects were reported, with similar rates of expected adverse events across trial arms. CONCLUSIONS: For adolescents referred to CAMHS after self-harm, who have self-harmed at least once before, FT confers no benefits over TAU in reducing self-harm repetition rates. There is some evidence to support the effectiveness of FT in reducing self-harm when caregivers reported poor family functioning. When the young person themselves reported difficulty expressing emotion, FT did not seem as effective as TAU. There was no evidence that FT is cost-effective when only the health benefits to participants were considered but there was a suggestion that FT may be cost-effective if health benefits to caregivers are taken into account. FT had a significant, positive impact on general emotional and behavioural problems at 12 and 18 months. LIMITATIONS: There was significant loss to follow-up for secondary outcomes and health economic analyses; the primary outcome misses those who do not attend hospital following self-harm; and the numbers receiving formal FT in the TAU arm were higher than expected. FUTURE WORK: Evaluation of interventions targeted at subgroups of those who self-harm, longer-term follow-up and methods for evaluating health benefits for family groups rather than for individuals. TRIAL REGISTRATION: Current Controlled Trials ISRCTN59793150. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 12. See the NIHR Journals Library website for further project information.

Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial.

BACKGROUND: Self-harm in adolescents is common and repetition occurs in a high proportion of these cases. Scarce evidence exists for effectiveness of interventions to reduce self-harm. METHODS: This pragmatic, multicentre, randomised, controlled trial of family therapy versus treatment as usual was done at 40 UK Child and Adolescent Mental Health Services (CAMHS) centres. We recruited young people aged 11-17 years who had self-harmed at least twice and presented to CAMHS after self-harm. Participants were randomly assigned (1:1) to receive manualised family therapy delivered by trained and supervised family therapists or treatment as usual by local CAMHS. Participants and therapists were aware of treatment allocation; researchers were masked. The primary outcome was hospital attendance for repetition of self-harm in the 18 months after group assignment. Primary and safety analyses were done in the intention-to-treat population. The trial is registered at the ISRCTN registry, number ISRCTN59793150. FINDINGS: Between Nov 23, 2009, and Dec 31, 2013, 3554 young people were screened and 832 eligible young people consented to participation and were randomly assigned to receive family therapy (n=415) or treatment as usual (n=417). Primary outcome data were available for 795 (96%) participants. Numbers of hospital attendances for repeat self-harm events were not significantly different between the groups (118 [28%] in the family therapy group vs 103 [25%] in the treatment as usual group; hazard ratio 1·14 [95% CI 0·87-1·49] p=0·33). Similar numbers of adverse events occurred in both groups (787 in the family therapy group vs 847 in the treatment as usual group). INTERPRETATION: For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, our family therapy intervention conferred no benefits over treatment as usual in reducing subsequent hospital attendance for self-harm. Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents. FUNDING: National Institute for Health Research Health Technology Assessment programme.

Self-Harm Intervention: Family Therapy (SHIFT), a study protocol for a randomised controlled trial of family therapy versus treatment as usual for young people seen after a second or subsequent episode of self-harm.

BACKGROUND: Self-harm is common in the community with a lifetime prevalence of 13 %. It is associated with an elevated risk of overall mortality and suicide. People who harm themselves are high users of public services. Estimates of the 1-year risk of repetition vary between 5 and 15 % per year. Currently, limited evidence exists on the effectiveness of clinical interventions for young people who engage in self-harm. Recent reviews have failed to demonstrate any effect on reducing repetition of self-harm among adolescents receiving a range of treatment approaches. Family factors are particularly important risk factors associated with fatal and non-fatal self-harm among children and adolescents. Family therapy focuses on the relationships, roles and communication patterns between family members, but there have been relatively few studies of specifically family-focused interventions with this population. The Self-Harm Intervention: Family Therapy (SHIFT) Trial was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (grant no. 07/33/01) following a commissioned call for this research. METHODS/DESIGN: SHIFT is a pragmatic, phase III, multicentre, individually randomised, controlled trial comparing Family Therapy (FT) with treatment as usual (TAU) for adolescents aged 11 to 17 who have engaged in at least two episodes of self-harm. Both therapeutic interventions were delivered within the National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) in England. Participants and therapists were, of necessity, aware of treatment allocation, but the researchers were blind to the allocations to allow unbiased collection of follow-up data. Primary outcome data (repetition of self-harm leading to hospital attendance 18 months post-randomisation) were collected from the Health and Social Care Information Centre (HSCIC), augmented by directed searches of medical records at Acute Trusts. Secondary outcome data (including suicidal intent, depression, hopelessness and health economics) were collected at 12 and 18 months post-randomisation via researcher-participant interviews and by post at 3 and 6 months. DISCUSSION: SHIFT will provide a well-powered evaluation of the clinical and cost effectiveness of Family Therapy for young people who have self-harmed on more than one occasion. The study will be reported in 2016, and the results will inform clinical practice thereafter. TRIAL REGISTRATION: ISRCTN59793150 . 26 January 2009.

Risk factors for suicide in Hungary: a case-control study.

BACKGROUND: Hungary previously had one of the highest suicide rates in the world, but experienced major social and economic changes from 1990 onwards. We aimed to investigate the antecedents of suicide in Hungary. We hypothesised that suicide in Hungary would be associated with both risk factors for suicide as identified in Western studies, and experiences related to social and economic restructuring. METHODS: We carried out a controlled psychological autopsy study. Informants for 194 cases (suicide deaths in Budapest and Pest County 2002-2004) and 194 controls were interviewed by clinicians using a detailed schedule. RESULTS: Many of the demographic and clinical risk factors associated with suicide in other settings were also associated with suicide in Hungary; for example, being unmarried or having no current relationship, lack of other social contacts, low educational attainment, history of self-harm, current diagnosis of affective disorder (including bipolar disorder) or personality disorder, and experiencing a recent major adverse life event. A number of variables reflecting experiences since economic restructuring were also associated with suicide; for example, unemployment, concern over work prospects, changes in living standards, practising religion. Just 20% of cases with evidence of depression at the time of death had received antidepressants. CONCLUSION: Suicide rates in Hungary are falling. Our study identified a number of risk factors related to individual-level demographic and clinical characteristics, and possibly recent societal change. Improved management of psychiatric disorder and self-harm may result in further reductions in suicide rates.

Pathways from adolescent deliberate self-poisoning to early adult outcomes: a six-year follow-up.

BACKGROUND: Prospective studies show that the adult outcomes of adolescents who deliberately harm themselves are marked by high rates of adversity and psychiatric disorders. The goal of this study was to identify pathways linking childhood risk factors to early adult outcomes of suicidal adolescents. METHODS: A clinical sample of 158 adolescents who deliberately poisoned themselves was followed up six years later. Eighty per cent of the cohort (n = 126) were interviewed in early adulthood using a battery of standardised measures of psychopathology and social functioning. RESULTS: Multivariate mediation path analysis identified four pathways linking child and adolescent risk factors to adverse outcomes in early adulthood. Family dysfunction, conduct disorder and hopelessness contributed to the risk of high adversity in early adulthood indirectly through its effect on other risk domains, including dropping out of school and adopting adult roles at a younger age. Hopelessness not only predicted dropping out of school but also independently contributed to the risk of chronic major depressive disorder in early adulthood. Child sexual abuse independently predicted high adversity and chronic major depression over and above the influence of hopelessness. Juvenile onset major depression independently predicted chronic major depression in early adulthood. A substantial proportion of the effects of child sexual abuse and hopelessness on the risk of deliberate self-harm in early adulthood was mediated by high adversity and the duration of major depression. However, chronic major depression was the only risk factor independently associated with deliberate self-harm in adulthood once correlation with adversity was taken into account. CONCLUSIONS: Chronic major depressive disorder is central to deliberate self-harm repetition. However, adult outcomes of suicidal adolescents are also dominated by the accumulating effects and consequences of other childhood risk factors, including child sexual abuse and adolescent hopelessness.

The health and well-being of neglected, abused and exploited children: the Kyiv Street Children Project.

OBJECTIVE: To report on the backgrounds and physical and emotional well-being of street children using two street shelters in Kyiv, Ukraine. This study is important because personal accounts of street children may highlight individual or family factors that are associated with vulnerability for and risk of poor mental health, and these could have serious repercussions for the future. This study also poses a challenge to research because street children are a highly elusive population that services find hard to reach. METHODS: Ninety-seven children were recruited and interviewed using a semistructured, psychosocial interview schedule; psychopathology was measured using the Strengths and Difficulties Questionnaire (SDQ) and the Mood and Feelings Questionnaire (MFQ). RESULTS: Seventy percent of street children scored for behavioral and emotional difficulties on the SDQ, and 74% scored for depression on the MFQ. Current health problems were reported by 78%, with 43% described as persistent or severe. Two thirds of the children in this sample were not homeless but had chosen life on the streets in preference to permanent residence with their families. Their "survival" history on the streets contributed to the development of three different profiles of vulnerability. CONCLUSIONS: High rates of physical and emotional problems in a population of street children, many of whom were still connected to their families, emphasize the importance of developing different approaches for children with different vulnerabilities. This study also demonstrates the feasibility of embedding on-going field research into the service dimension of "front-line" social care agencies.

Early adult outcomes of adolescents who deliberately poisoned themselves.

OBJECTIVE: To describe the early adult psychopathological and social outcomes of adolescents who deliberately poisoned themselves. METHOD: Prospective cohort study with a 6-year follow-up of 132 of 158 (84%) adolescents who, between ages 11 and 16 years, had taken part in a randomized trial of a brief family intervention after deliberate self-poisoning. Comparisons were made with a sample of participants matched for age, gender, and childhood social class. Both groups were assessed using standardized measures of psychopathology and social functioning. RESULTS: In most cases (93/132 or 70%) self-harm stopped within 3 years. Psychiatric disorders, particularly depression (74/132 or 56%), were prevalent, and self-harm in adulthood was restricted to this subgroup. There was a strong association between childhood adversity, in particular childhood sexual abuse, and self-harming risk in adulthood. Adulthood adversity also added to the risk, especially for those who had experienced index episode major depression. These associations were not mediated by childhood problem solving and hopelessness. CONCLUSIONS: For some young people, deliberate self-poisoning in adolescence seems to be part of a complex and continuing network of problems, marked by high rates of psychopathology, comorbidity, with other disorders and high psychosocial adversity.

A step too far? Randomized trial of cognitive-behaviour therapy delivered by social workers to depressed adolescents.

OBJECTIVE: To test the hypothesis that depressed adolescents given brief cognitive behaviour therapy by trained social workers will be less depressed after this treatment than depressed adolescents who have routine care from their social workers. METHOD: Open study, two randomized parallel groups. 86 social workers were randomized to training in brief CBT or delayed training by remote telephone randomization. 25 social workers who attended CBT training recruited 29 depressed adolescents. 22 social workers in the control group recruited 23 depressed adolescents. RESULTS: Social workers' perceptions of their knowledge and skills in dealing with adolescent depression were better after the training than before. However, in intention to treat analyses, adolescents who had therapy from trained social workers had a similar level of depression post treatment (mean depression score 17.5, 95% CI 11.8 to 23.3) to those who did not have such therapy (mean depression score 16.7, 95 % CI 11.3 to 22.1). There were no significant differences between the groups on other outcomes or at follow-up. CONCLUSIONS: This study failed to recruit enough cases and probably did not therefore have enough statistical power to detect an effect of the intervention. It was also based on a severely impaired sample with many comorbid problems. However, the results suggest that training community-based social workers in cognitive behaviour therapy is neither practical nor effective in improving the outcomes of their clients.

A Home and School Support Project for Children Excluded from Primary and First Year Secondary School.

BACKGROUND: In the last 10 years the problem of exclusion has reached a crisis point. Research suggests that exclusion is a complex phenomenon that needs involvement from all the involved services such as Health, Education and Social Services. METHOD: One hundred and twenty-four pupils, aged 4-12 years who, through school and social exclusion, were at risk of developing more serious mental health difficulties, were randomly allocated to standard care (n = 62) or standard care plus the new intervention (n = 62). RESULTS: There were no significant differences in the primary outcomes between the two groups at either of the outcome assessments. However, the intervention group with non-compliance cases removed from the analysis did significantly better ( p < . 014, 95%CI -12.8 to -1.4). CONCLUSIONS: The Home and School Support project managed to reduce the number of excluded days and the appearance of mental health symptoms for pupils who engaged fully with the intervention. The project also highlights the importance of multi-agency involvement at a very early stage.

Social Services and CAMHS: A National Survey.

BACKGROUND: Links between Social Service Departments (SSDs) and CAMHS are explored and described through a national survey and a number of site visits. METHOD: Data were collected via (1) a national questionnaire survey yielding a response rate of 75%, and (2) pre-selected site visits to seven SSDs. RESULTS: Additional to existing CAMHS assessment and treatment provision to SSDs, there is increasing outreach consultation and support, some provided through primary mental health workers and dedicated clinical psychology sessions. Some SSDs have developed innovative in-house provision for Tier 2 type referrals. CONCLUSIONS: Outreach and core CAMHS provision to SSDs need equal investment and development.