Can temporary textual content messaging scale back repeat hospital-treated self-harm?

Self-harm is outlined as “intentional self-poisoning or damage, no matter the obvious objective” (Nationwide Institute for Well being and Care Excellence, 2022, p. 81). Charges of self-harm have turn out to be extra prevalent, with 25.7% of ladies, and 9.7% of males, reporting self-harm throughout their life (McManus et al., 2016). Differential charges of self-harm have been reported for many who determine as LGBTQ+ (Liu et al., 2019), these from non-white ethnic backgrounds (Bhui et al., 2007) and people from disadvantaged socio-economic backgrounds (Geulayov et al., 2022). Self-harm can also be linked with suicidality (Geulayov et al., 2019). Total, self-harm is a fancy and life-threatening phenomenon; one which warrants vital consideration.

The current research, by Stevens and colleagues (2024), seeks to determine whether or not a quick textual content message intervention may support in decreasing the variety of instances that individuals have to return to hospital for self-harm remedy. The randomised managed trial (RCT), by Steven and colleagues (2024), is the primary to discover this kind of intervention on a broader inhabitants in Australia. Earlier analysis has been centered on particular populations, like navy personnel, due to this fact, this research has the potential to contribute to the interventions’ generalisability to a wider group of individuals.

Strategies

Stevens et al., (2024) performed a parallel RCT which in contrast contributors who acquired remedy as normal (TAU), with contributors who acquired TAU, plus 9 temporary quick message service (SMS) messages over 12 months, after their discharge from three hospitals in New South Wales, Australia.

The SMS intervention included three totally different messages despatched to contributors on a rotating schedule. All SMS messages had been personalised with the contributors title, included an expression of concern for participant wellbeing, and included particulars of obtainable native psychological well being companies and disaster strains. The messages had been developed by consultants with lived expertise.

As soon as enrolled, contributors had been stratified by first and subsequent self-harm presentation as there was vital variability amongst contributors. After stratification, contributors had been then randomly assigned and enrolled by clinicians into both the TAU or TAU plus SMS situation. The allocation sequence was hid.

The research additionally curiously used a single-consent Zelen design (Zelen, 1979) which has been mentioned in earlier a earlier weblog by Lucy Maconick (2022). The Zelen design is a modification to a normal RCT, whereby contributors within the intervention group solely are requested to offer consent after randomisation. Because the research used a Zelen design, this meant that the contributors weren’t blinded to being within the SMS situation.

Outcomes

The research enrolled 431 contributors into the TAU group and 373 contributors into the TAU plus SMS group. There was a bigger proportion of females (n=520) to males (n=284). The research had major three main outcomes, and two secondary outcomes.

Main outcomes

• The variety of instances that individuals repeated self-harm, and wanted hospital remedy for this, diminished considerably at 12 and 24 months, after receiving TAU plus the SMS intervention, with a relative threat discount (RRR) of twenty-two%. The authors state that on the 24-month follow-up, this 22% equates to 123 much less folks re-presenting for self-harm remedy within the SMS group.
• Females had larger charges of re-presentation for self-harm, however the impact of the temporary textual content message was vital and bigger for females in comparison with males, the place there was no distinction between TAU and TAU plus intervention concerning the frequency of repeat, hospital handled, self-harm.
• There was no distinction, between TAU and TAU plus intervention, within the time between when contributors first introduced to hospital with self-harm, to once they introduced to hospital once more for self-harm, over the 24-month follow-up interval.

Secondary outcomes

• There was no distinction between TAU and TAU plus intervention concerning the proportion of contributors who repeated self-harm or not, over the 24-month follow-up interval of the research, that means the intervention didn’t scale back the variety of instances folks repeated self-harm.
• All through the research, over the 24-month interval, there have been a complete of 16 deaths.
• The research additionally analysed suicide charges amongst the 16 deaths and sadly discovered that there have been 4 suicides throughout the 24-month interval. The authors acknowledged that the suicides occurred within the TAU group solely.

Conclusions

Total, this research exhibits {that a} temporary textual content message intervention may scale back the variety of instances that individuals return to hospital for remedy of repeat self-harm. The authors additionally state that “the 22% discount in repetition of hospital-treated self-harm was clinically significant” (Stevens et al., 2024, p. 106). This is a vital discovering, given how simply implementable such an intervention could possibly be, as it’s temporary and automatic. Nonetheless, the authors argue that it’s probably that extra research are wanted to ascertain additional efficacy and financial feasibility of the SMS intervention.

Strengths and limitations

The RCT, by Stevens et al., (2024), was the primary to discover a quick SMS intervention in a inhabitants past a slim demographic. By exploring a wider inhabitants, this research offered proof that the intervention may have efficacy in hospital settings, the place a big proportion of the inhabitants search self-harm remedy. As this was an RCT, the research was randomised, which is one other energy, as this helps to enhance inside validity. It was additionally good to see that messages included within the intervention had been created by folks with lived psychological well being expertise, probably enhancing their appropriateness.

Nonetheless, the research used non-standardised TAU situation. Though this could possibly be argued as extra correct, as there may be variability in medical settings, it may confound outcomes. Witt et al. (2018) state that non-standard TAU is a major supply of heterogeneity in research that examine self-harm interventions, and it’s crucial to have readability concerning what constitutes TAU. Though the authors did element what TAU was more likely to include, they acknowledged that it different, which may have influenced outcomes. For instance, if one participant acquired a care plan that didn’t embrace psychological therapies, in comparison with one other participant that did obtain psychological therapies, this might have triggered confounding variables.

One other major limitation was the single-consent Zelen design. Though the Zelen design can enhance drop-out charges, as contributors could also be happier to be allotted to the remedy situation (Homer, 2002), the single-consent Zelen design requested for consent within the remedy group solely, which the authors state led to elevated attrition charges, which may have led to attrition bias. Contributors within the remedy situation had been additionally conscious of their allocation, which may have altered participant behaviour, finally impacting the validity of the research. Moreover, the research didn’t clarify whether or not the researchers had been blinded, so this may increasingly have additional impacted the findings.

Implications for observe

Self-harm is a major burden on the wellbeing of the Australian inhabitants (Australian Institute of Well being and Welfare, 2019), due to this fact the implications of the discount in repeat self-harm occasion charges are vital for sufferers, companies and practitioners.

Qualitative analysis has demonstrated that temporary SMS interventions could also be useful to people who find themselves self-harming by fostering a way of feeling supported by means of caring messages, and details about companies, if pressing psychological well being assist is required (Duan et al., 2020). This strategy to affected person aftercare due to this fact could scale back demand on stretched Australian emergency departments (Australian Institute of Well being and Welfare, 2023), as messages encourage sufferers to make use of assist helplines for preventative self-harm care. Nonetheless, previous to implementation, additional analysis should discover why sufferers are re-presenting much less, and whether or not disaster strains, or supportive messages, are an informal mechanism by which re-presentation charges are diminished. Understanding the precise informal mechanisms will guarantee interventions are efficacious, ease demand, and obtain the most effective outcomes when it comes to self-harm discount.

Because the UK experiences the identical difficulties as Australia, like excessive demand for pressing companies (Pines et al., 2011), and will increase in self-harm (McManus et al., 2016), the identical implications apply. Because the NHS strikes in direction of offering Enhanced Main Care Companies, which embrace psychological well being companies for folks with extra advanced displays, such an intervention could supply practitioners an simply implementable software which may assist scale back escalation to secondary care and enhance psychological well being literacy; each outcomes have the potential to boost affected person security and expertise in main care, particularly for extra at-risk sufferers. Additional analysis is required to discover an SMS intervention in main care settings to find out the efficacy of the intervention.

Lastly, the cost-effectiveness of the intervention have to be examined. There’s proof to recommend that digital well being interventions may be cost-effective (Gentili et al., 2022), which may make an SMS intervention possible within the NHS, with out including vital monetary burden. Within the Speaking Therapies service that I work inside, the service has a longtime automated SMS service, which could be the case throughout different companies, so it could possibly be simply implementable with little further sources.

Total, a quick SMS intervention could possibly be applied inside psychological well being companies to cut back burden on pressing companies and enhance the wellbeing of the recipients, nonetheless, extra analysis is required concerning mechanisms of change, generalisability and financial viability earlier than adoption.

Assertion of pursuits

No conflicts of curiosity to declare.

Hyperlinks

Main paper

Stevens, G. J., Sperandei, S., Carter, G. L., Munasinghe, S., Hammond, T. E., Gunja, N., de la Riva, A., Brakoulias, V., & Web page, A. (2024). Efficacy of a brief message service temporary contact intervention (SMS-SOS) in decreasing repetition of hospital-treated self-harm: randomised managed trial. The British Journal of Psychiatry, 224(3), 106–113. https://doi.org/10.1192/bjp.2023.152

Different references

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Duan, S., Wang, H., Wilson, A., Qiu, J., Chen, G., He, Y., Wang, Y., Ou, J., & Chen, R. (2020). Growing a Textual content Messaging Intervention to Cut back Deliberate Self-Hurt in Chinese language Adolescents: Qualitative Research. JMIR MHealth and UHealth, 8(6), e16963. https://doi.org/10.2196/16963

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Geulayov, G., Casey, D., Bale, L., Model, F., Clements, C., Farooq, B., Kapur, N., Ness, J., Waters, Ok., Tsiachristas, A., & Hawton, Ok. (2019). Suicide following presentation to hospital for non-fatal self-harm within the Multicentre Research of Self-harm: a long-term follow-up research. The Lancet Psychiatry, 6(12), 1021–1030. https://doi.org/10.1016/S2215-0366(19)30402-X

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