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Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning

  • Gregory L. Carter (a1), Kerrie Clover (a2), Ian M. Whyte (a3), Andrew H. Dawson (a4) and Catherine D'Este (a5)...
Abstract
Background

Repetition of hospital-treated self-poisoning and admission to psychiatric hospital are both common in individuals who self-poison.

Aims

To evaluate efficacy of postcard intervention after 5 years.

Method

A randomised controlled trial of individuals who have self-poisoned: postcard intervention (eight in 12 months) plus treatment as usual v. treatment as usual. Our primary outcomes were self-poisoning admissions and psychiatric admissions (proportions and event rates).

Results

There was no difference between groups for any repeat-episode self-poisoning admission (intervention group: 24.9%, 95% CI 20.6-29.5; control group: 27.2%, 95% CI 22.8-31.8) but there was a significant reduction in event rates (incidence risk ratio (IRR)=0.54, 95% CI 0.37-0.81), saving 306 bed days. There was no difference for any psychiatric admission (intervention group: 38.1%, 95% CI 33.1-43.2; control group: 35.5%, 95% CI 30.8-40.5) but there was a significant reduction in event rates (IRR=0.66, 95% CI 0.47-0.91), saving 2565 bed days.

Conclusions

A postcard intervention halved self-poisoning events and reduced psychiatric admissions by a third after 5 years. Substantial savings occurred in general hospital and psychiatric hospital bed days.

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Copyright
Corresponding author
Gregory Carter, Department of Consultation-Liaison Psychiatry, Locked Bag #7, Hunter Region Mail Centre NSW 2310, Australia. Email: gregory.carter@newcastle.edu.au
Footnotes
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Declaration of interest

None.

Footnotes
References
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Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning

  • Gregory L. Carter (a1), Kerrie Clover (a2), Ian M. Whyte (a3), Andrew H. Dawson (a4) and Catherine D'Este (a5)...
Submit a response

eLetters

Postcards from the Edge; Causal link between intervention and outcome not clear.

Dr Muhammad Suleman, Dr Muhammad Suleman, Doctor - GP trainee ST2
05 July 2013

We looked at this study with great interest, being a GP trainee in psychiatry in the National Health Service in England, which is in a midst of significant change1. Looking at it from a health improvement and cost utilisation perspective, the potential reduction of resources to manage the complex problem of self harm is encouraging. However we would like to draw attention to a few limitations which are not clearly mentioned in thestudy and we would like to highlight them so that commissioners do not solely base their decisions on this paper alone. The primary outcome showsreduction in numbers if admissions to psychiatric hospitals and numbers ofreadmission to acute hospitals thus suggesting cost effectiveness, but we feel that the causal relationship was not established

*Significantly, Confounding factors which are potentially likely to have contributed to reduced admission for both groups are not accounted for. Nor was the methodology used appropriate for the same. Cohort studiesare prone to be affected by confounding factors and Confounding variables are viewed as the principal contributor to a false positive test2. Data for 153 participants was missing for employment at the beginning of the study. Moreover, there is no data on how many participants subsequently married or had children which are known to be strong protective factors3. As mentioned in the paper, a variety of therapies have evidenced reductionof self harm. It is disappointing the appropriate methodology to record therapies patient received during the course of 4 years post intervention was not used..

*Although number for psychiatric diagnosis was matched in both groups we are not clear on diagnosis and subsequent treatment they received. The study could have potentially identified data on outpatient'sattendance, other therapy, and primary care intervention.

*Negative binomial regression was used to report incidence risk ratio. A full regression analysis should have been considered to demonstrate potential4 association & a further variation to study may have been useful to test for biological variance which would help better understanding of correlation.

Finally, we would very much like to believe in a low cost intervention with a massive potential but the results seem too good to be true. A causal link as suggested in the paper seem premature due to a variety of factors as described above and could also be counter-productiveis services are watered down based on this outcome in the cash strapped NHS.

References;

1)Prescribed specialised services Commissioning intentions for 2013/14 2012. Prepared by the Specialised Services Commissioning Transition Team. http://www.england.nhs.uk/wp-content/uploads/2012/11/comm-int.pdf

2)Bookwala A, Hussain N, Bhandari M. The three-minute appraisal of aprospective cohort study. Indian J Orthop 2011; 45 :291-3

3)Ping Qin, M.D., Ph.D.; Esben Agerbo, M.Sc.; Preben Bo Mortensen, Dr.Med.Sc. Suicide Risk in Relation to Socioeconomic, Demographic, Psychiatric, and Familial Factors: A National Register-Based Study of All Suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160: 765-772.

4)Readers guide to critical appraisal of cohort studies: 3. Analytical strategies to reduce confounding BMJ 2005;330:1021.

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Conflict of interest: None declared

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