Supplementary appendix

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1 Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Hawton K, Witt KG, Taylor Salisbury TL, et al. Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. Lancet Psychiatry 2016; published online July 12.

2 PART A: Electronic search strategy. CCDANCTR (Date range searched: to ). 1. ((deliberat* or self*) NEXT (destruct* or harm* or injur* or mutilat* or poison*)):ab,ti,kw,ky,emt,mh,mc 2. DSH:ab 3. (parasuicid* or para suicid* ) 4. (suicid* NEAR2 (attempt* or episod* or frequen* or future or histor* or multiple or previous* or recur* or repeat* or repetition)):ab,ti,kw,ky,emt,mh,mc 5. post suicid* 6. (suicid* and (BPD or borderline personality disorder )) 7. (overdos* or over dos* ) 8. ((crisis or suicid*) NEAR (emergenc* or hospital or outpatient or repeat* attend* or frequent* attend* )): ab,ti,kw,ky,emt,mh,mc 9. (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8) EMBASE, MEDLINE, PreMEDLINE, PsycINFO (OVID SP interface) (Date range searched: to ). 1. automutilation/ or drug overdose/ or exp suicidal behavior/ 2. 1 use emez 3. overdose/ or self-injurious behavior/ or self mutilation/ or suicide/ or suicidal ideation/ or suicide, attempted/ 4. 3 use mesz, prem 5. drug overdoses/ or self destructive behavior/ or exp self injurious behavior/ or attempted suicide/ or suicidal ideation/ or suicide/ or suicide prevention/ or suicide prevention centers/ or suicidology/ 6. 5 use psyh 7. (auto mutilat$ or automutilat$ or cutt$ or head bang$ or head bang$ or overdos$ or (self adj2 cut$) or self destruct$ or selfdestruct$ or self harm$ or selfharm$ or self immolat$ or selfimmolat$ or self inflict$ or selfinflict$ or self injur$ or selfinjur$ or selfmutilat$ or self mutilat$ or self poison$ or selfpoison$ or suicid$).ti,ab. 8. or/2,4, exp clinical trial (topic) / or exp clinical trial/ or crossover procedure/ or double blind procedure/ or placebo/ or randomization/ or random sample/ or single blind procedure/ use emez 11. exp clinical trial/ or exp clinical trials as topic / or cross-over studies/ or double-blind method/ or placebos/ or random allocation/ or single-blind method/ use mesz, prem 13. (clinical trials or placebo or random sampling).sh,id use psyh 15. (clinical adj2 trial$).ti,ab. 16. (crossover or cross over).ti,ab. 17. (((single$ or doubl$ or trebl$ or tripl$) adj2 blind$) or mask$ or dummy or doubleblind$ or singleblind$ or trebleblind$ or tripleblind$).ti,ab. 18. (placebo$ or random$).ti,ab. 19. treatment outcome$.md. use psyh 20. animals/ not human$.mp. use emez 21. animal$/ not human$/ use mesz 22. (animal not human).po. use psyh 23. (or/10,12,14-19) not (or/20-22) and 23 1

3 CENTRAL (Wiley interface) (Date range searched: t o ). #1. MeSH descriptor: [Drug Overdose], this term only #2. MeSH descriptor: [Self-Injurious Behavior], this term only #3. MeSH descriptor: [Self Mutilation], this term only #4. MeSH descriptor: [Suicide], this term only #5. MeSH descriptor: [Suicide, Attempted], this term only #6. MeSH descriptor: [Suicidal Ideation], this term only #7. auto mutilat* or automutilat* or cutt* or head bang* or headbang* or overdos* or self destruct* or selfdestruct* or self harm* or selfharm* or self immolat* or selfimmolat* or self inflict* or selfinflict* or self injur* or selfinjur* or selfmutilat* or self mutilat* or self poison* or selfpoison* or suicid*:ti #8. auto mutilat* or automutilat* or cutt* or head bang* or head bang* or overdos* or self destruct* or selfdestruct* or self harm* or selfharm* or self immolat* or selfimmolat* or self inflict* or selfinflict* or self injur* or selfinjur* or selfmutilat* or self mutilat* or self poison* or selfpoison* or suicid*:ab #9. #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 Notes: ab: abstract; ti: title; kw: keywords; ky: additional keywords; emt: EMTREE headings; mh: MeSH headings; mc: MeSH checkwords. 2

4 PART B: List of interventions investigates in two or fewer randomised controlled trials (RCTs). Behaviour therapy Intervention Dialectical behaviour oriented therapy Dialectical behaviour therapy (vs. treatment by expert) Dialectical behaviour therapy (vs. prolonged exposure protocol) Emergency green cards General hospital admission General Practitioner (GP) letters Group-based emotion regulation therapy Full Trial Reference Liberman RP, Eckman T. Behavior therapy vs insight oriented therapy for repeated suicide attempters. Arch Gen Psychiatry 1981;38: Turner RM. Naturalistic evaluation of dialectical behaviour therapy-oriented treatment for borderline personality disorder. Cognitive and Behavioral Practice 2000;7: Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006;63: Harned MS, Korslund KE, Linehan MM. A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther 2014;55:7 17. Evans MO, Morgan HG, Hayward A, Gunnell DJ. Crisis telephone consultation for deliberate self-harm patients: Effects on repetition. British Journal of Psychiatry 1999;175:23 7. Morgan HG, Jones EM, Owen JH. Secondary prevention of non-fatal deliberate self-harm. The green card study. Br J Psychiatry 1993;163: Waterhouse J, Platt S. General hospital admission in the management of parasuicide. A randomised controlled trial. Br J Psychiatry 1990;156: Bennewith O, Stocks N, Gunnell D, Peters TJ, Evans MO, Sharp DJ. General practice based intervention to prevent repeat episodes of deliberate self harm: Cluster randomised controlled trial. British Medical Journal 2002;324: Gratz KL, Gunderson JG. Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behav Ther 2006;37: Gratz KL, Tull MT, Levy R. Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Psychol Med 2013;44:

5 Intervention Home-based problem-solving therapy (vs. alternative forms of psychotherapy) Information and support Full Trial Reference Hawton K, Bancroft J, Catalan J, Kingston B, Stedeford A. Domiciliary and out-patient treatment of self-poisoning patients by medical and nonmedical staff. Psychol Med 1981;11: Fleischmann A, Bertolote JM, Wasserman D, et al. Effectiveness of brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bull World Health Organ 2008;86: Intensive inpatient and community treatment van der Sande R, van Rooijen L, Buskens E, et al. Intensive in-patient and community intervention versus routine care after attempted suicide. A randomised controlled intervention study. Br J Psychiatry 1997;171: Intensive outpatient treatment Allard R, Marshall M, Plante MC. Intensive follow-up does not decrease the risk of repeat suicide attempts. Suicide Life Threat Behav 1992;22: Welu T. A follow-up program for suicide attempters: Evaluation of effectiveness. Suicide Life Threat Behav 1977;7: Interpersonal problem-solving skills training (vs. alternative forms of psychotherapy) McLeavey B, Daly R, Ludgate J, Murray C. Interpersonal problem-solving skills training in the treatment of self-poisoning patients. Suicide Life Threat Behav 1994;24: Long-term psychotherapy (vs. alternative forms of psychotherapy) Torhorst A, Möller HJ, Kurz A, Schmid-Bode W, Lauter H. Comparing a 3-month and a 12-month-outpatient aftercare program for parasuicide repeaters. In: Möller HJ, Schmidtke A,Welz R editor(s). Current Issues of Suicidology. Berlin, Germany: Springer-Verlag, 1988: Mentalisation Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009;166: Mixed multi-modal interventions Hatcher S, Coupe N, Wikirwhi K, Durie M, Pillai A. Te Ira Tangaga: A Zelen randomised controlled trial of a treatment package including problem solving therapy compared to treatment as usual in Māori who present to hospital after self-harm. Unpublished manuscript Hatcher S, Sharon C, House A, Collins N, Collings S, Pillai A. The ACCESS study: Zelen randomised controlled trial of a package of care for people presenting to hospital after self-harm. Br J Psychiatry 2015;206: Mobile-telephone psychotherapy Marasinghe RB, Edirippulige S, Kavanagh D, Smith A, Jiffry MTM. Effect of mobile phone-based psychotherapy in suicide prevention: A randomized controlled trial in Sri Lanka. Journal of Telemedicine and Telecare 2012;18:

6 Intervention Full Trial Reference Telephone contact Cedereke M, Monti K, Ojehagen A. Telephone contact with patients in the year after a suicide attempt: Does it affect treatment attendance and outcome? A randomised controlled study. Eur Psychiatry 2002;17: Vaiva G, Ducrocq F, Meyer P, et al. Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: Randomised controlled study. BMJ 2006;332: Wei S, Liu L, Bi B, et al. An intervention and follow up study following a suicide attempt in the emergency departments of four general hospitals in Shenyang, China. Crisis 2013;34: Treatment compliance/adherence enhancement approaches Torhorst A, Möller HJ, Bürk F, Kurz A, Wächtler C, Lauter H. The psychiatric management of parasuicide patients: A controlled clinical study comparing different strategies of outpatient treatment. Crisis 1987;8:53 61 van Heeringen C, Jannes S, Buylaert W, Hendrick H, de Bacquer D, van Remoortel J. The management of noncompliance with referral to outpatient after-care among attempted suicide patients: A controlled intervention study. Psychol Med 1995;25:

7 PART C: Study characteristics and methodological details of the 29 randomised controlled trials (RCTs) included in this review. Study Country INV N CTL Age (SD) Cognitive behavioural-based psychotherapy vs. TAU Brown (2005) USA (10.3) Female History of self-harm Participant Source Davidson (2014) UK 14 6 NS NS NS Admissions to accident and emergency medical wards. Dubois (1999) France (5.8) Duration of Treatment Measures Hospital presentations weeks. Self-harm: self-reported repetition. Depression: Beck Depression Inventory and Hamilton Rating Scale for Depression NS Emergency department presentations. NS. Self-harm: self-reported repetition. Depression: Hospital Anxiety and Depression Scale (depression sub-scale). Suicidal ideation: Beck s Scale for Suicidal Ideation. 1 month. Self-harm: NS. Evans (1999) UK NS Admissions to hospital. 6 months. Self-harm: self-reported repetition. Depression: Hospital Anxiety and Depression Scale (depression sub-scale). Suicide: outcome not reported. Gibbons (1978) UK NS 71.0 NS Presentations to an accident and emergency department. 3 months. Self-harm: medical and/or hospital records. Problem-solving: self-report. Suicide: outcome not reported. Risk of Bias Participants, clinical personnel, and outcome assessors not blind to allocation. and clinical personnel not blind to allocation. Imbalance between intervention and control groups in terms of history of previous self-harm, anxiety, and depression scores. Authors did not adjust for these differences in their analyses. and clinical personnel not blind to allocation. Unclear if outcome assessor also not blind to allocation. Less than two-thirds of participants in the intervention group attended all three treatment sessions. and clinical personnel not blind to allocation. Five participants in the intervention group did not see a therapist and instead received bibliotherapy whilst one further participant received no intervention. and clinical personnel not blind to allocation. 6

8 Study Country INV N CTL Age (SD) Female Cognitive behavioural-based psychotherapy vs. TAU (continued) Guthrie (2001) UK (1.5) Hatcher (2011) New Zealand (12.9) Hawton (1987) UK (NS) Husain (2014) Pakistan (5.5) History of self-harm Participant Source Duration of Treatment Measures Hospital presentations. 4 weeks. Self-harm: self-reported repetition supplemented by information from a collateral informant and/or from hospital/clinical records. Suicidal ideation: Beck s Scale for Suicidal Ideation Admissions to hospital. 3 months. Self-harm: representation to hospital. Depression: Hospital Anxiety and Depression Scale (depression sub-scale). Suicidal ideation: Beck s Scale for Suicidal Ideation. Problem-solving: Social Problem Solving Inventory Revised. Suicide: Coroner s records Admissions to hospital. NS. Self-harm: self-reported repetition. Problem-solving: self-reported. Suicide: Collateral informant report Admissions to a hospital medical unit. 3 months. Self-harm: self-reported repetition. Suicidal ideation: Beck s Scale for Suicidal Ideation. Problem-solving: Coping Resource Inventory. Risk of Bias and clinical personnel not blind to allocation. Although outcome assessors blind to allocation, data on repetition of SH obtained from selfreport. not blind to allocation. Clinical personnel not blind to allocation. and clinical personnel not blind to allocation. blind to allocation. 7

9 Study Country INV N CTL Age (SD) Female Cognitive behavioural-based psychotherapy vs. TAU (continued) McAuliffe (2014) Ireland (11.8) History of self-harm Participant Source Admissions to emergency department or an acute psychiatric unit. Patsiokas (1985) USA 10 5 NS NS NS Admissions to a psychiatric ward. Salkovskis (1990) UK (6.7) Slee (2008) Netherlands (5.5) Assessed in emergency department by duty psychiatrist NS Admissions to emergency department or mental health centre. Duration of Treatment Measures 6 weeks. Self-harm: mixed methods. Self-reported repetition (6 month follow-up), representation to hospital (12 month follow-up). Suicidal ideation: Beck s Scale for Suicidal Ideation. Problem-solving: Means-Ends Problem Solv-ing test and Self-Rated Problem Solving Scale. Suicide: hospital/medical records. 3 weeks. Self-harm: outcome not reported. Suicidal ideation: Beck s Scale for Suicidal Ideation. Problem-solving:Means-Ends Problem Solving Suicide: outcome not reported. 1 month. Self-harm: NS. Problem-solving: Personal Questionnaire Rapid Scaling Technique. 5.5 months. Self-harm: self-reported repetition. Problem-solving: Coping Inventory for Stressful Situations (coping subscale). Stewart (2009) Australia 23 9 NS 53.1 NS Admissions to hospital. 2 months. Self-harm: NS. Suicidal ideation: Beck s Scale for Suicidal Ideation. Risk of Bias blind to allocation. and outcome assessors not blind to allocation. As same therapist delivered intervention and control therapies, clinical personnel also not blind to allocation., clinical personnel, and outcome assessors not blind to allocation. Participants, clinical personnel, and outcome assessors not blind to allocation. Of the 90 participants randomised, eight did not receive the intervention. Reasons for this were not stated. Participants, clinical personnel, and outcome assessors not blind to allocation. Data only collected on treatment completers. 8

10 Study Country N INV CTL Age (SD) Female History of self-harm Participant Source Cognitive behavioural-based psychotherapy vs. TAU (continued) Tapolaa (2010) Finland (NS) 100 NS Admissions to emergency department. Tyrer (2003) UK (11.0) Wei (2013) China (12.9) Weinberg (2006) USA (8.2) Duration of Treatment 67.9 NS Admissions to hospital. Between 3-6 months NS Admissions to emergency department. Dialectical behaviour therapy vs. TAU Linehan (1991) USA NS Referrals to a personality disorder service. Measures 4 weeks. Self-harm: self-reported repetition. Self-harm: self-reported repetition supplemented by information from a collateral informant and/or from hospital/clinical records. Depression: Hospital Anxiety and Depression Scale (depression sub-scale). Suicide: Coroner s records. 3 months. Self-harm: self-reported repetition. Depression: Hamilton Rating Scale for Depression. Suicidal ideation: self-reported. Suicide: Collateral informant report. 100 NS Community referrals. 2 months. Self-harm: self-reported repetition. Suicidal ideation: Suicide Behaviors Quest-ionnaire (suicide ideation subscale). 12 months. Self-harm: self-reported repetition. Suicidal ideation: Scale for Suicidal Ideators. Risk of Bias and outcome assessors not blind to allocation. Outcome assessor not blind to allocation. Data only collected on treatment completers., clinical personnel, and outcome assessors not blind to allocation., clinical personnel, and outcome assessors not blind to allocation., clinical personnel, and outcome assessors not blind to allocation. and clinical personnel not blind to allocation. Data from 24/63 (38.1%) participants omitted from 24 month follow-up assessment. 9

11 Study Country INV N CTL Age (SD) Dialectical behaviour therapy vs. TAU (continued) McMain (2009) Canada (9.9) Priebe (2012) UK (10.8) Case management vs. TAU or EUC Clarke (2002) UK (NS) Hvid (2011) Denmark (17.9) Kawanishi (2014) Japan (14.9) Female History of self-harm Participant Source Referrals to an addiction and mental health unit Referrals to a specialist DBT service. Duration of Treatment Measures 12 months. Self-harm: self-reported repetition. 12 months. Self-harm: self-reported repetition Presentations to hospital. Up to 6 months. Self-harm: representation to hospital Admissions to hospital or clinical services Admissions to emergency departments. 6 months. Self-harm: self-reported repetition supplemented by information from a collateral informant and/or from hospital/clinical records. Suicide: Coroner s records. 18 months. Self-harm: NS. Although results for this outcome scheduled for publication at a later date. Suicide: mortality statistics. Risk of Bias blind to allocation. blind to allocation. blind to allocation. blind to allocation. blind to allocation. Outcomes appeared to be determined ad hoc and, additionally, data on some prespecified outcomes (e.g., number of repeat self-harm episodes, hopelessness scores) are yet to be published. 10

12 Study Country INV N CTL Age (SD) Case management vs. TAU or EUC (continued) Morthorst (2012) Denmark (13.2) Postcards vs. TAU Beautrais (2010) New Zealand (NS) Female History of self-harm Participant Source Admissions to acute emergency units, intensive care, paediatric units or psychiatric emergency rooms Admissions to psychiatric emergency services. Carter (2005) Australia NS Presentations to a hospitalbased toxicology service Hassanian-Moghaddam (2011) Iran (8.1) Admissions to a specialist poisons hospital. Kapur (2013) UK NS NS NS Admissions to emergency department. Duration of Treatment Measures 6 months. Self-harm: self-reported repetition supplemented by information from a collateral informant and/or from hospital/clinical records. Suicide: hospital/medical records. 12 months. Self-harm: representation to hospital. 12 months. Self-harm: representation to hospital. Suicide: mortality statistics. 12 months. Self-harm: self-reported repetition. Suicidal ideation: self-reported. Suicide: collateral report supplemented by medical records and/or Coroner s records. 12 months. Self-harm: representation to hospital. Risk of Bias blind to allocation. Participants not blind to allocation. Imbalance between intervention and control groups for number with prior admissions for self-harm. Adjusting for this reduced effect on repetition of self-harm to non-significance. blind to allocation. Twenty participants randomised to control group mistakenly received intervention but were included in control group for all analyses. not blind to allocation. Outcome assessors not blind to allocation. and clinical personnel not blind to allocation. Notes: history of SH refers to the proportion of the participants with at least one episode of SH prior to the index episode. Age for Carter (2005) presented as median (interquartile range) of 33 years (24-44 years). For Wei (2013) only data from the CBT-based psychotherapy and control groups were used in the present review. Data for the telephone intervention arm of this trial can be found in the related Cochrane review. CTL: control; DBT: dialectical behaviour therapy; ED: emergency department; EUC: enhanced usual care; INV: intervention; MH: mental health; NS: not specified; NSSI: non-suicidal self-injury; PD: personality disorder; TAU: treatment as usual. 11

13 PART D: Additional forest plots for secondary outcomes included in this review. Cognitive behavioural-based psychotherapy vs. TAU. Random effects mean difference (MD) and accompanying 95% confidence intervals for effectiveness on frequency of self-harm by the 12 month (final follow-up) assessment. Cognitive behavioural-based psychotherapy vs. TAU. Random effects standard mean difference (SMD) and accompanying 95% confidence intervals for depression scores at 6, 12, and 24 months follow-up. 12

14 Cognitive behavioural-based psychotherapy vs. TAU. Random effects mean difference (MD) or standard mean difference (SMD) and accompanying 95% confidence intervals for hopelessness scores at post-intervention, 6 and 12 months follow-up. Cognitive behavioural-based psychotherapy vs. TAU. Random effects mean difference (MD) or standard mean difference (SMD) and accompanying 95% confidence intervals for suicidal ideation scores at post-intervention, 6, 12, and 24 months follow-up. 13

15 Cognitive behavioural-based psychotherapy vs. TAU. Random effects standard mean difference (SMD) and accompanying 95% confidence intervals for problem solving scores at postintervention and 6 months follow-up. DBT vs. TAU. Random effects mean difference (MD) and accompanying 95% confidence intervals for effectiveness on frequency of self-harm and scores for depression, hopelessness and suicidal ideation scores at post-intervention and 24 months follow-up. 14

16 Postcards vs. TAU. Random effects mean difference (MD) and accompanying 95% confidence intervals for effectiveness on frequency of self-harm at post-intervention, 12 and 24 months follow-up. 15

17 PART E: Funnel plots for cognitive behavioural-based psychotherapy versus TAU for repetition of self-harm at 6 and 12 months follow-up. Repetition of self-harm (SH) at 6 months: Repetition of self-harm (SH) at 12 months: 16