Self harm in adolescents is a major public health problem in many countries. It is associated with recurrent psychosocial problems1 2
and poor long term outcome,3
and it may mark an emerging personality disorder.4
Self harm tends to recur; the reported risk of repetition in adolescents ranges from 10% within six months to 42% during a 21-month follow-up, with a median recurrence of 5-15% each year.5
The risk of suicide after self harm in adolescence is around 0.1-0.5% over 10 years2 6
with retrospective studies reporting a repetition rate of 36% over 10-12 years7
and lifetime mortality rates of 4-11%.8 9
Self harm shows comorbidity with axis I psychiatric disorders in 43% to 70% of cases, with evidence that the number of comorbid conditions is associated with increased risk of a serious suicide attempt.10
Around two thirds of children and adolescents presenting with self harm score positively for depressive disorders11 12 13 14 15
; suicidal adolescents with chronic and recurrent affective illness are at increased risk of repetition.11 16 17 18
The persistence of major depressive disorder predicts substantially increased risk of further self harm in young adulthood when other factors are controlled.19
The incidence of self harm is increasing in some areas of the UK.20
Self harming adolescents contribute substantially to the workload of health services, in terms of both emergency risk assessment and longer term management. A further substantial burden is placed on wider social care and education. At the time of a self harm event, the young person commonly presents to an accident and emergency department; current National Institute for Health and Clinical Excellence (NICE) guidance1
for England and Wales is for overnight medical hospital admission as a minimum response and more lengthy medical or psychiatric admission is often needed in situations of risk or more severe disorder. A follow-up study of young adults who had deliberately poisoned themselves as adolescents21
found that their lifetime service costs were significantly greater than those of matched controls. They used more service provided accommodation, special education, and hospital services, incurred greater criminal justice costs, and received more social security benefits.
Despite this large burden, very little is known about the cost-effectiveness of interventions.22
In one of the few studies to date, Byford and colleagues23
undertook a cost-effectiveness analysis of a home based social work intervention for children and adolescents who deliberately poisoned themselves. They found no significant differences between the two groups in terms of the main outcome measures or costs, although in a subgroup of children without major depression, suicidal ideation was significantly lower in the intervention group at follow-up with no significant differences in cost.
The design and delivery of effective treatments for this group are complex and have to accommodate considerable variations in presentation.1
A subgroup of patients needs emergency inpatient management; the majority require long term treatment approaches in the context of multi-agency partnerships. A Cochrane review of psychosocial and pharmacological treatments for self harm24
found continuing uncertainty about which forms of treatment are most effective and insufficient evidence against which to make firm recommendations. Across all age ranges, a promising additional benefit over standard care was found for problem solving therapy (summary odds ratio across five studies 0.70; 0.45 to 1.11) and provision of an emergency contact card (summary odds ratio across two studies 0.45; 0.19 to 1.07), but neither of these results reached statistical significance. The authors noted a number of key limitations across all studies reviewed. These included insufficient sample sizes, leading to possible type 2 errors in effectiveness estimates; lack of adequate description of the services used as comparison groups; and use of service data (usually further hospital attendance) rather than interview data to define the primary outcome of repetition, which could introduce biases in outcome estimates, owing to variation in service use and the possibility that the intervention itself could alter willingness to seek hospital help.
Hawton and colleagues24
noted that only two of the studies reviewed focused on adolescent self harm, despite the importance of the problem in this age group and the likelihood that the treatment needs of adolescents differ from those of adults. Trials of adolescent focused treatments are therefore of high priority to inform service provision. Harrington and colleagues15
tested a brief family intervention for adolescents (total n=149) against standard aftercare and found no significant effect on repetition (odds ratio 1.02; 95% CI 0.41 to 2.5; P=0.97). The same group then undertook a developmental group psychotherapy programme designed to focus on the multiple clinical problems typical in this population (depression, experience of abuse, behavioural disorder, substance misuse, poor self esteem and body image, and family conflict and disruption) and to combine effectively with other interventions (pharmacotherapy, individual and family therapies) using a group therapy format that was cost-effective of clinician time. A pilot randomised trial of developmental group psychotherapy compared with routine care in 63 adolescents referred with repeated self harm to child and adolescent mental health services25
showed a significant relative reduction of repeated self harm over 29 weeks of follow-up (2/31 in developmental group psychotherapy versus 10/31 in routine care; odds ratio 6.3; 95% CI 1.4 to 28.7). The total number of self harm episodes per participant during follow-up was also lower for the treatment group (mean 0.6) than for the routine care group (mean 1.8), but this difference was not statistically significant. This trial was one of the few to have suggested effectiveness of an intervention in patients of any age. A replication in northern Australia, with remote supervision from the UK developing team (n=72)26
failed to show a treatment effect. This study, however, recruited from general referrals to child and adolescent mental health services where patients were identified to have self harming behaviour, rather than from specific self harm referrals, and it only recruited 57% of its target for analytical power.
The Assessment of Treatment In Suicidal Teenagers (ASSIST) trial reported here was intended as a definitive test of this group intervention using a large sample with a pragmatic design and including a detailed health economic evaluation. Our objective was to use a large parallel group randomised trial to compare the effectiveness and cost-effectiveness of developmental group psychotherapy plus routine care with that of routine care alone for adolescents presenting with repeated self harm in the previous year. We addressed some of the methodological weaknesses in previous studies identified by Hawton and colleagues24
by recruiting a large cohort size, making detailed description of routine treatment undertaken, and triangulating two independent interview based ascertainments of the primary outcome rather than using service data on hospital attendance.