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An exploratory randomised trial of a simple, brief psychological intervention to reduce subsequent suicidal ideation and behaviour in patients admitted to hospital for self-harm

  • Christopher J. Armitage (a1), Wirda Abdul Rahim (a2), Richard Rowe (a2) and Rory C. O'Connor (a3)
Abstract
Background

Implementation intentions link triggers for self-harm with coping skills and appear to create an automatic tendency to invoke coping responses when faced with a triggering situation.

Aims

To test the effectiveness of implementation intentions in reducing suicidal ideation and behaviour in a high-risk group.

Method

Two hundred and twenty-six patients who had self-harmed were randomised to: (a) forming implementation intentions with a ‘volitional help sheet’; (b) self-generating implementation intentions without help; or (c) thinking about triggers and coping, but not forming implementation intentions. We measured self-reported suicidal ideation and behaviour, threats of suicide and likelihood of future suicide attempt at baseline and then again at the 3-month follow-up.

Results

All suicide-related outcome measures were significantly lower at follow-up among patients forming implementation intentions compared with those in the control condition (ds>0.35). The volitional help sheet resulted in fewer suicide threats (d = 0.59) and lowered the likelihood of future suicide attempts (d = 0.29) compared with patients who self-generated implementation intentions.

Conclusions

Implementation intention-based interventions, particularly when supported by a volitional help sheet, show promise in reducing future suicidal ideation and behaviour.

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Copyright
Corresponding author
Chris Armitage, Manchester Centre for Health Psychology, School of Psychological Sciences, Manchester Academic Health Science Centre, University of Manchester, Coupland Street, Oxford Road, Manchester M13 9PL, UK. Email: chris.armitage@manchester.ac.uk
Footnotes
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Declaration of interest

None.

Footnotes
References
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3 O'Connor, RC, Rasmussen, S, Beautrais, A. Recognition of suicide risk, crisis helplines, and psychosocial interventions: a selective review. In International Handbook of Suicide Prevention: Research, Policy and Practice (eds O'Connor, RC, Platt, S, Gordon, J): 435–56. Wiley-Blackwell, 2011.
4 Hjelmeland, H, Hawton, K, Nordvik, H, Bille-Brahe, U, De Leo, D, Fekete, S, et al. Why people engage in parasuicide: a cross-cultural study of intentions. Suicide Life Threat Behav 2002; 32: 380–93.
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9 Armitage, CJ. Effectiveness of experimenter-provided and self-generated implementation intentions to reduce alcohol consumption in a sample of the general population: a randomized exploratory trial. Health Psychol 2009; 28: 545–53.
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An exploratory randomised trial of a simple, brief psychological intervention to reduce subsequent suicidal ideation and behaviour in patients admitted to hospital for self-harm

  • Christopher J. Armitage (a1), Wirda Abdul Rahim (a2), Richard Rowe (a2) and Rory C. O'Connor (a3)
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eLetters

Clarification with respect to House and Owens' observations

Christopher J. Armitage, Professor Health Psychology, University of Manchester
Wirda Abdul Rahim, Lecturer, University of Technology, Malaysia
Richard Rowe, Reader in Psychology, University of Sheffield
Rory C. O'Connor, Professor of Health Psychology, University of Glasgow
12 July 2016

We welcome the opportunity to reply to House and Owens’ two observations. We will address House and Owens’ concerns in the order in which they present them, namely, the title and limitations associated with the methodology, respectively.

First, the title does not say that suicidal behaviour was changed. The title states that the aim of the intervention was "to reduce subsequent suicidal ideation and behaviour”. Moreover, we insisted on the term “exploratory” remaining in the title against the suggestion of a reviewer and explicitly did not present the 6 month outcomes as main findings.

Second, House and Owens are correct that there are methodological limitations to the study, but these are recognised in the paper. Indeed, the final sentence of our conclusion chimes with the points they raise; "Further research is required to replicate the findings with a more complete data-set and objective outcome measures." In total we highlighted six points of caution with respect to the interpretation of the findings. Methodological limitations are inherent in exploratory studies of this kind but we endeavoured to address them by making weaknesses explicit and adjusting analyses to mitigate the effects of limitations as far as possible.

We believe our approach of Last Observation Carried Forward is a good example of adjustment to the limitation of missing data here. As House and Owens note, the observation carried forward method is not perfect and may introduce bias, which we assumed most readers would be well aware of and therefore did not flag in our “limitations” section. In terms of the present study, the observation carried forward was pre-intervention, rather than post-intervention. Given that our randomisation check demonstrated no differences between conditions pre-intervention, any score carried forward would, if anything, bias results against finding an effect of the intervention. Had we chosen instead to measure outcomes immediately post-intervention and carried these observations forward then the findings would have been biased in favour of finding an effect of the intervention. We would therefore argue that, cognizant of the limitations of Last Observation Carried Forward per se, we adopted the most rigorous approach possible within the given context (i.e., a busy emergency department in a developing country).

Another example of our attempt to make limitations explicit concerns

the points we make about the measurement of the main outcome variable. It was not possible to record re-attendance following non-fatal self-harm and so we had to rely on the use of the Suicidal Behaviours Questionnaire - a self-report measure of suicidal ideation and behaviour. In the discussion we state, “it would be useful to have a more objective outcome measure, such as future hospital admissions, although this is not currently possible in the Malaysian context”. It behooves us to conduct research such as ours in developing countries, even if it can only be exploratory at the present time.

In sum, we stand by our conclusion that this paper details a promising approach to intervention that is worthy of further research.

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Conflict of interest: None Declared

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Article's conclusions are not warranted

Allan House, Professor of Liaison Psychiatry, University of Leeds
David Owens, Associate Professor, University of Leeds
10 June 2016

We take issue with the presentation of this study’s findings, on two counts.

First, the title is misleading because there is no evidence that the intervention reduced suicidal behaviour, which was not measured as an outcome – not even through the obvious mechanism of recording re-attendance following non-fatal self-harm. Neither is it entirely accurate to imply, as the title does, that the intervention was designed to reduce suicidal behaviour: in the body of the paper the authors indicate that they did not nominate a primary outcome measure because – in what they call an exploratory trial - they weren’t clear what effects they expected.

Second, there is a stage at which flaws in the design or delivery of a trial mean that no safe conclusions can be drawn from it. Loss to follow up of 50-60% at 3 months and >85% at 6 months is not compatible with a plausible intention-to-treat analysis and using Last Observation Carried Forward cannot rescue the situation – especially when (as here) the Last Observations in question are pre-intervention baseline measures taken at the same time as participants were given the materials for the intervention to which they had been randomised. The authors indicate that they are aware of some of the other problems with their trial – for example outcomes not collected by researchers blinded to allocation and uncorrected analysis of multiple outcomes. Under the circumstances their conclusion that their intervention showed promise – a conclusion about which they were surely not in initial equipoise – cannot be regarded as sound.

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Conflict of interest: None Declared

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