Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: An extended follow up of pragmatic randomised controlled trial.

BACKGROUND: Self-harm in adolescents is common and repetition frequent. Evidence for effective interventions to reduce self-harm is limited. Long term follow-up of existing studies is rare. METHODS: Extended follow up, from 18 to at least 36-months, of the SHIFT trial: a pragmatic, multi-centre, individually-randomised, controlled trial involving young people (11-17) who had self-harmed at least twice and presented to Child & Adolescent Mental Health Services (CAMHS). SHIFT evaluated manualised family therapy (FT) versus treatment as usual (TAU) in reducing repetition of self-harm leading to hospital attendance 18 months post-randomisation.We obtained ONS mortality data, adult mental health data, and further details of hospital attendance from routine Hospital Episode Statistics (HES) data plus researcher follow-up. We assessed longer-term differences in outcome using multivariable Cox Proportional Hazards regression analysis, and assessed all-cause mortality and morbidity relating to hospital attendances for reasons other than self-harm. STUDY REGISTRATION: ISRCTN 59793150. OUTCOMES: The original sample of 832 were randomised between April 2010 and December 2013. Extended follow-up continued until February 2017 for a median 55·4 months (range 0-82·5 months), providing post 18-month data for 804 (96·6%) participants, of whom 785 (94·4%) had a minimum of 36-months follow-up.There was no evidence of a between-group difference in the primary outcome during the extended follow-up period (Hazard Ratio (HR) 1·03; 95% CI: 0·83, 1·28; p-value=0·78), consistent with our findings in the original trial with 18 months follow-up (HR 1·14, 95% CI 0·87, 1·49; p-value 0·33). There was a reduced rate of self-harm in older participants aged 15-17 (HR 0·7, 95% CI 0·56, 0·88), as compared with those aged 11-14; and significantly increased rates of self-harm in participants whose index episode combined self-injury and poisoning (HR 1·8, 95% CI 1·2, 2·7). Two deaths were reported during the extended follow up period. INTERPRETATION: For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, trial FT confers no benefits over TAU in reducing subsequent hospitalisation for self-harm over 18 months or 36 months. FUNDING: NIHR HTA Reference: 07/33/01.

Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation.

OBJECTIVE: To examine the effectiveness and cost-effectiveness of group therapy for self harm in young people. DESIGN: Two arm, single (assessor) blinded parallel randomised allocation trial of a group therapy intervention in addition to routine care, compared with routine care alone. Randomisation was by minimisation controlling for baseline frequency of self harm, presence of conduct disorder, depressive disorder, and severity of psychosocial stress. PARTICIPANTS: Adolescents aged 12-17 years with at least two past episodes of self harm within the previous 12 months. Exclusion criteria were: not speaking English, low weight anorexia nervosa, acute psychosis, substantial learning difficulties (defined by need for specialist school), current containment in secure care. Setting Eight child and adolescent mental health services in the northwest UK. INTERVENTIONS: Manual based developmental group therapy programme specifically designed for adolescents who harm themselves, with an acute phase over six weekly sessions followed by a booster phase of weekly groups as long as needed. Details of routine care were gathered from participating centres. MAIN OUTCOME MEASURES: Primary outcome was frequency of subsequent repeated episodes of self harm. Secondary outcomes were severity of subsequent self harm, mood disorder, suicidal ideation, and global functioning. Total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses, were recorded. RESULTS: 183 adolescents were allocated to each arm (total n = 366). Loss to follow-up was low (<4%). On all outcomes the trial cohort as a whole showed significant improvement from baseline to follow-up. On the primary outcome of frequency of self harm, proportional odds ratio of group therapy versus routine care adjusting for relevant baseline variables was 0.99 (95% confidence interval 0.68 to 1.44, P = 0.95) at 6 months and 0.88 (0.59 to 1.33, P = 0.52) at 1 year. For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to 1.20, P = 0.29) at 6 months and 0.94 (0.63 to 1.40, P = 0.75) at 1 year. Total 1 year costs were higher in the group therapy arm (£21,781) than for routine care (£15,372) but the difference was not significant (95% CI -1416 to 10782, P = 0.132). CONCLUSIONS: The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations. Trial registration ISRCTN 20496110.

Deliberate self-poisoning in adolescence: why does a brief family intervention work in some cases and not others?

In a randomized trial of a brief family intervention with adolescents who had deliberately poisoned themselves, we have previously reported that, within the group of patients who did not have major depression, the family intervention was significantly superior to routine care in reducing suicidal thinking. The present paper examined whether efficacy was related to changes in family functioning or other possible mediating variables. Potential mediators included family functioning, hopelessness, depression, adolescent problem-solving and compliance with treatment. The efficacy of the family intervention in reducing suicidal ideation within the non-depressed sub-group was probably not mediated by changes in these variables. The implications of this finding are discussed.

Developing needs led child and adolescent mental health services: issues and prospects.

For many years mental health services for children have been developed incrementally with little attention to the needs of the local population. However, over the past decade there have been attempts to develop more rational ways of planning child mental health services. This paper describes the information required to develop a needs-led child mental health service and, within that context, discusses how priorities should be set. It will be suggested that although the assessment of needs for child and adolescent mental health services is still very haphazard, there is now a clear trend for the evaluation of clinical practice to become more systematic. At an individual level we know quite a lot about the efficacy of treatment and the measurement of outcomes. At the service level, several models of good practice are being specified and evaluated.

Cost-effectiveness analysis of a home-based social work intervention for children and adolescents who have deliberately poisoned themselves. Results of a randomised controlled trial.

BACKGROUND: Little evidence exists regarding the effectiveness or cost-effectiveness of alternative treatment services in the field of child and adolescent psychiatry. AIMS: To assess the cost-effectiveness of a home-based social work intervention for young people who have deliberately poisoned themselves. METHOD: Children aged < or = 16 years, referred to child mental health teams with a diagnosis of deliberate self-poisoning were randomly allocated to either routine care (n = 77) or routine care plus the social work intervention (n = 85). Clinical and resource-use data were assessed over six months from the date of trial entry. RESULTS: No significant differences were found between the two groups in terms of the main outcome measures or costs. In a sub-group of children without major depression, suicidal ideation was significantly lower in the intervention group at the six-month follow-up (P = 0.01), with no significant differences in cost. CONCLUSIONS: A family-based social work intervention for children and adolescents who have deliberately poisoned themselves is as cost-effective as routine care alone.

Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves.

OBJECTIVE: To establish whether an intervention given by child psychiatric social workers to the families of children and adolescents who had attempted suicide by taking an overdose reduced the patients' suicidal feelings and improved family functioning. METHOD: One hundred sixty-two patients, aged 16 or younger, who had deliberately poisoned themselves were randomly allocated to routine care (n = 77) or routine care plus the intervention (n = 85). The intervention consisted of an assessment session and four home visits by the social workers to conduct family problem-solving sessions. The control group received no visits. Both groups were assessed at the time of recruitment and 2 and 6 months later. The primary outcome measures were the Suicidal Ideation Questionnaire, the Hopelessness Scale, and the Family Assessment Device. RESULTS: There were no significant differences in the primary outcomes between the intervention and control groups at either of the outcome assessments. Parents in the intervention group were more satisfied with treatment (mean difference 1.4 [95% confidence interval 0.6 to 2.1]). A subgroup without major depression had much less suicidal ideation at both outcome assessments (analysis of covariance p < .01) compared with controls. CONCLUSIONS: The home-based family intervention resulted in reduced suicidal ideation only for patients without major depression.

Correlates and short-term course of self-poisoning in adolescents.

BACKGROUND: The features of adolescents who had taken an overdose were assessed to determine the focus for a treatment trial. METHOD: Overdose cases were compared with psychiatric and community controls who had not taken an overdose in respect of mental disorders and family background. RESULTS: Overdose cases had high rates of major depression, but most of them recovered from depression within six weeks of the overdose. There was a specific association between taking an overdose and family dysfunction. CONCLUSIONS: Family dysfunction could be a useful focus in a clinical trial of the aftercare of adolescents who have taken an overdose.

Variation in requests to social services departments for assessment for compulsory psychiatric admission.

Eighty-two local authority social services departments in England and Wales participated in a postal survey of their responses to psychiatric emergencies, and 52 of the authorities provided detailed information on the rates of requests made to them for assessments under the Mental Health Act, 1983. This paper reports upon the variation in the rates of requests in different types of local authorities and regions. Variations are related to the availability of approved social workers (ASWs) and the Jarman Index of social deprivation. Requests for assessment and treatment order (Sections 2 and 3) are related to a greater number of ASWs, but only in county authorities, and requests for emergency admission (Section 4) are related to greater social deprivation, but only in London. Possible explanations for these findings are considered. Requests for the use of treatment orders have increased since the Act was introduced and now stand at more than one third of all requests, whereas requests for the use of emergency orders have declined to fewer than 8% of all requests.

The outcome of childhood suicidal behaviour.

A group of children under 16 years of age who were admitted to hospital after episodes of deliberate self-poisoning, were followed up after one year. Ninety of the original sample of 100 were traced, and interviewed. Almost half of the subjects were improved after one year but the remaining children continued disturbed. Improvement was most marked in relation to "school problems" and "running away from home". There was significant improvement for some children in their family relationships. Ten per cent of children had been involved in further self-poisoning during the follow-up period. Extended follow-up some seven years later traced 41 of the original subjects. The repetition rate for self-poisoning was 20% although the majority of these episode occurred within a year of the original self-poisoning. Overall, the situation of subjects was judged as improved by them and their families although significant psycho-social difficulties remained for some.

Tryptamine alkaloid toxicosis in feedlot sheep.

Tryptamine alkaloid toxicosis (Phalaris staggers) was diagnosed in feedlot sheep. Clinical signs of toxicosis, which were exacerbated by excitement, included gait abnormalities, muscular tremors, nystagmus, and convulsions. An estimated 8% of the most severely affected lambs had clinical signs of toxicosis. Gross lesions detected in the brain of affected lambs consisted of focal gray-green discoloration in the brain stem and thalamus; these areas had microscopic evidence of intraneuronal pigment accumulation. Brain specimens obtained at slaughter indicated that 60% of the lambs had lesions consistent with tryptamine alkaloid toxicosis. Tryptamine alkaloids were found in low concentrations in the feed. Lambs exposed to these feeds had higher death losses than those that were not exposed to the feeds. Cobalt concentration in the feed was higher than that previously reported to be associated with Phalaris staggers.

Deliberate self-poisoning in childhood and early adolescence.

One hundred children under 16 yrs of age, who were admitted to hospital following an episode of deliberate self-poisoning, were compared with 50 psychiatric, non-suicidal controls, proportionally matched for age and sex. The self-poisoners showed more delinquency, school problems, previous self-poisoning, running away, and previous experience of "Care" than did the psychiatric controls. Their families showed more evidence of marital failure, previous psychiatric disorder, self-poisoning, and delinquency, than was present in control families. Their presentation was often acute, though usually within the setting of long-term, chronic difficulties, and emphasises the need for skilled and careful assessment.

The purification of nicotinamide nucleotide-dependent dehydrogenases on immobilized cofactors.

1. The general applicability of affinity chromatography to the purification of nicotinamide nucleotide-dependent dehydrogenases on immobilized cofactors is illustrated with several examples taken from crude systems. 2. Methods for overcoming the inevitable loss of selectivity experienced with these polymers are suggested. Effective use of the appropriate nucleotide, the second substrate and other interacting ligands can be made to selectively alter the chromatographic behaviour of the desired enzyme.