With reference to Evans et al (Reference Evans, Morgan and Hayward1999), it is not clear from the paper whether the ‘green card’ treatment group really received a different treatment from the control group. Did the control group receive advice concerning methods of accessing mental health services in the future (e.g. the general practitioner, crisis centre, ward, community psychiatric nurses, Samaritans)? This is particularly relevant as approximately 50% of each group were referred on to mental health services. This would have negated the effect of the green card as a valid different treatment intervention.

It would be helpful to know how many patients used the telephone support service after having been given the green card. It is possible that a poor telephone support service could have caused the apparent lack of positive outcome in the study. One wonders about the availability of on-call psychiatric trainees and their level of expertise in giving telephone counselling; additional information about this in the paper would have been appreciated.

The patients who had a history of repeated deliberate self-harm, probably represent a more vulnerable group, as stated in the paper, but they may also be a group who habitually use deliberate self-harm as a method of communication. Therefore, paying increased attention (in the form of the green card) to this dysfunctional behaviour may have exacerbated the behaviour.