Self-harm in a time of isolation: What is the evidence to support mobile and internet-based psychological interventions for self-harm?

Dr. Alexandra Pitman and Dr. Sarah Rowe
Dr. Alexandra Pitman is an Associate Professor in the UCL Division of Psychiatry and an Honorary Consultant Psychiatrist at Camden and Islington NHS Foundation Trust. Her research and clinical interests are in the epidemiology of suicide and self-harm, the relationship between loneliness and suicidality, the effects of media reporting of suicide, and in psychosocial interventions for people with suicidal thoughts. She completed her PhD in 2014 at UCL on the impact of suicide bereavement and is funded by the American Foundation for Suicide Prevention to continue research on this topic. She is a Patron of the Support After Suicide Partnership, and tweets in a personal capacity as @DrAPitman. Dr. Sarah Rowe is an Associate Professor and Deputy Director of the MSc Mental Health Sciences programme in the Division of Psychiatry, UCL. She is a Senior Fellow of the Higher Education Academy. Sarah’s research interests include harm-minimisation for self-harm, mental health help-seeking in young people and digital interventions. She can occasionally be found on Twitter @KiwiRowebot

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Summary

In this blog we summarise the findings and implications of a recent systematic review of studies evaluating the effectiveness and acceptability of mobile- and internet-based psychological interventions for self-harm in adolescents and adults. The COVID-19 pandemic means that mental health services need to adapt quickly to the clinical need for remote care at a time when we anticipate an increase in the incidence and severity of depression and anxiety. There are already particular concerns about adolescents, who have had to adjust to major changes in their schooling or employment, their home environment and family dynamics, and in their social interactions at a critical stage of development. Their need for digital mental health interventions has never been greater. However, digital delivery of psychological interventions should not compromise effectiveness, acceptability, or equitable access.

Only six of the 22 papers included in this systematic review focused on young people aged 18 years and under, but given the paucity of studies (and systematic reviews) on this topic we felt it was important to appraise the evidence presented with a view to its application to adolescent mental health service delivery. This review found limited evidence to support the effectiveness of mobile- and internet-based interventions to address suicidal thoughts and behaviour in adolescents (and adults), and no indication that a particular modality (text messages, mobile apps, internet-based modules) was superior to others. One of the two studies using blended (therapist contact and remote therapy) interventions was found to reduce suicidal ideation to a greater degree over time than a waiting-list control although this was trialled in an adult population.

In this blog, we also consider how NHS mental health services might respond in terms of implementing findings from research on mobile- and internet-based psychological interventions for self-harm in adolescents and adults, paying particular attention to equitable access to services.

Background

There are approximately 220,000 presentations to British Accident and Emergency (A&E) departments annually by adolescents and adults who have self-harmed (1). These estimates suggest that the majority of presentations (62.9%) are by people aged under 35 years, represented particularly by adolescent females aged 15-19 years and males aged 20-24 years (1). Appropriate clinical care for these patients is of key importance to address the distress they experience, but also their elevated risk of subsequent suicide (2;3). However, self-harm that results in presentation to clinical services such as A&E or to general practitioners (GPs) represents only the tip of the iceberg in adolescents, and self-harm that occurs in the community is much more common (4). A 2015 Cochrane review of interventions for self-harm in children and adolescents concluded that there was weak evidence to support group-based psychotherapy  to reduce repetition of self-harm, and  that further evaluation was needed of dialectical behaviour therapy (DBT), mentalisation and therapeutic assessment to determine their effectiveness in this age group (5). No studies identified in that review delivered therapy online, and no evidence was identified to support the use of remote contact interventions (5).  When we searched, we could only find one previous systematic review on web-based and mobile interventions targeting adolescent suicidal behaviour (6). Their review was limited to only one study and two protocols, highlighting the lack of adequate research on this topic at that time.

To set this in the context of evidence for adults who self-harm, a 2016 Cochrane review of psychosocial interventions for self-harm in adults concluded that there was weak evidence to support cognitive-behavioural therapy (CBT) based psychological therapy to reduce repetition of self-harm, and also weak evidence to support dialectical behaviour therapy (DBT) for people with multiple episodes of self-harm (7). No studies identified in that review delivered therapy online, and no evidence was identified to support the use of remote contact interventions (7).  The need to evaluate interventions that can be delivered remotely, by telephone or internet, is more pressing than ever in view of the current COVID-related restrictions on face-to-face contact, the anticipated rise in the incidence of self-harm in adolescents and adults (8) and of common mental disorders (9) during and after the COVID-19 crisis, and the likely long-term requirement for vulnerable groups to self-isolate. This timely review summarises such evidence on mHealth (mobile health) and eHealth (website health) technology in relation to self-harm. Although it includes findings from both adolescent and adult populations, we feel it is important to discuss this paper in light of the paucity of evidence focusing on mHealth for adolescent suicidal behaviour, and to highlight interventions for potential adaption to this population.

What they did

Arshad and colleagues brought together evidence from all single-arm and controlled trials of interventions evaluating mobile- and internet-based psychological interventions for self-injurious thoughts and behaviour, a term that covers self-harm, thoughts of self-harm, and suicidal thoughts. There were no restrictions on the age of those included in the study. They searched four electronic databases using terms reflecting a broad range of self-harm behaviours, up until March 2019. They followed good practice in hand-searching reference lists, contacting corresponding authors, screening citations independently, using the Cochrane Collaboration risk of bias tool in appraising included papers independently, populating a data extraction spreadsheet independently, and using meta-analysis where feasible. The sample characteristics for each study are clearly presented in the table so that you can identify the six studies using adolescent samples as compared to those sampling adult populations. A further strength of this review was that it explored effectiveness, acceptability, and feasibility and was thus pragmatic in its relevance to those planning services. However, the inclusion criteria were very broad with respect to the inclusion of uncontrolled studies beyond the limited number of twelve RCTs identified, which probably reflected the relatively early stage of evaluating these interventions.

What they found

The authors identified 22 eligible trials, involving 2,106 adult and adolescent participants, and these included nine single-arm studies (with no control), one cross-over study, and 12 RCTs. Only one was from a low or middle-income country (LMIC), which was disappointing given that the majority of suicide deaths occur in such countries. Six of the 22 studies sampled adolescent populations, with the mean age approximately 15 years. A further two studies included samples with a mean age ranging from 23 to 25 years. Adolescent settings included high school students, psychiatric outpatient clinics and psychiatric inpatient units. Outcomes measured included frequency or occurrence of repeat self-harm, or degree of suicidal ideation, using a range of validated and unvalidated measures, and measures of acceptability. Methodological quality was variable, and many studies were judged to be at high risk of reporting bias and other biases.

Interventions:

Text message Website Mobile phone App
Supportive text messages after discharge. Four messages sent over 10 days **Eleven modules of individualised emotion regulation therapy delivered over 12 weeks Suicide prevention including virtual ‘hope box’, signposting and coping skills. Delivered over 6-12 weeks
Supportive text messages delivered over 4 weeks encouraging help-seeking Eight modules of CBT and DBT principles delivered over 6 weeks **Face-to-face therapy supplemented with CBT and DBT informed skills from mobile app
Supportive text messages delivered over 6 months Mobile phone and computer app of Therapeutic Evaluative Conditioning (self-harm related stimuli paired with aversive stimuli) delivered over 1 month

Face-to-face and telephone intervention followed up with reminder text messages about coping skills, use of support and signposting. Delivered over 12 months. †

 

**CBT delivered across 8 modules over 10 weeks. Focused on suicidal thinking and behaviour **Suicide prevention app providing signposting and coping skills. Modules also available to support parents.
Autobiographical Self-Enhancement Training (writing task focusing on positive personal characteristics), delivered over 4 weeks Psychoeducation, self-assessment, safety-planning and self-help exercises
 Unguided self-help based on CBT and DBT principles Provides coping strategies in a suicidal crisis, based on CBT principles, safety and crisis planning. Delivered over 1 week
Six online modules based on CBT and DBT principles delivered over 6 weeks Face-to-face therapy supported by app with DBT skills training and coaching across four modules. App available for 9 months†
DBT skills training delivered over 8 weeks **Toolbox of strategies based on CBT and DBT principles. Delivered over 12 weeks
Suicide prevention skills training including mindfulness, self-soothing and acceptance-based techniques. Three modules delivered over 6 weeks

† blended interventions (mHealth/eHealth with face-to-face support)

**Interventions used in adolescent populations

Key findings

  1. Limited evidence to support the effectiveness of mobile- and internet-based interventions to address suicidal thoughts and behaviour for both adolescents and adults.
  2. No indication that a particular modality (text messages (only used in adult samples), mobile apps, internet-based modules) was superior to others.
  3. There was evidence to support the acceptability of mobile and internet-based interventions, but areas which could be refined include providing clearer instructions, more intuitive interfaces, distilling the number of modules, and careful piloting to develop contingencies for technical problems.

Meta-analysis could only be conducted on studies using suicidal thoughts as an outcome, and this found no strong evidence to support the active interventions, except where confined to those compared to treatment as usual rather than control tasks or treatments. Positive findings from single-arm studies (i.e. with no control) identify promising interventions that could be trialled formally following evidence of acceptability, but this evidence is of limited interest in relation to effectiveness, as it is hard to disentangle any positive effects from a tendency to improve over time without treatment.

Generally, acceptability data regarding accessibility and helpfulness were good, except for those for an online writing task trialled in adults because participants found it hard to understand the instructions. Findings on the feasibility of interventions related to data on initial engagement in the interventions trialled, which were positive for all interventions evaluated. Studies involving adults showed that they tended to drop out of web-based modules after three to five modules, particularly in the face of technical difficulties. However, it was also possible that this reflected participants making a clinical improvement and no longer needing the intervention. Completion rates for studies involving adolescents tended to be good, perhaps suggesting greater acceptability and feasibility of eHealth and mHealth interventions in this age group.

Limitations

The limitations of the review have been appropriately acknowledged in the paper (exclusion of non-English papers, small number of papers, heterogeneity of interventions). The findings of a meta-analysis involving heterogeneous interventions and assessment tools, and studies of low to moderate quality must also be interpreted with caution. Although it closely follows a previous 2017 review (10), and coincides with a 2020 review (11), both on this area, it also adds important acceptability data.

Implications

The concerns that clinicians may have about the use of remote therapies in adolescents and adults who self-harm includes the lack of a thorough face-to-face assessment, using visual cues and clues to develop a formulation, and a reduced capacity for the collaborative development of understanding. There are also risk issues in being constrained in responding to distress or risk situations. The authors suggest that mobile- and internet-based interventions might be improved by integrating them with a real-world therapist but acknowledge that we need trials of such blended interventions. One such approach would be to use an initial phone-based assessment to inform a collaborative formulation, and develop therapeutic alliance, before directing the patient towards an appropriate mobile- or internet-delivered therapy.

The development of such treatments obviously relies on having access to a range of mobile- and internet-based modalities, and this is a task that psychological therapy services will need to rise to under the current circumstances. Ideally, they should be supported by computer scientists, software engineers, young people with lived experience, and mental health scientists in a collaborative approach. Careful thought must also be given to access issues, instead of assuming a high prevalence of digital access among young people, both in terms of having their own device and also to a private space in which to engage in an eHealth or mHealth intervention.

Conclusions

Mental health service providers and patients reading this review may feel disappointed at the lack of strong evidence to support mobile- and internet-based interventions for self-harm in either adolescents or adults, but this review does highlight  some promise in the range of acceptable components identified. We would suggest that local services use the studies in this review as the starting point for considering what they might develop locally, collaborating with academic partners nationally to conduct controlled trials and thinking carefully about access issues in all age groups.  We would also recommend that the authors update this review regularly, in view of the plethora on trials of online therapies anticipated and the hope that these will improve in methodological rigour over time to address this important clinical area.

Conflicts of interest

A.P. is employed by UCL and conducts clinical work as a consultant psychiatrist at Camden and Islington NHS Foundation Trust, where she assesses and treats patients who self-harm. She receives grant funding from the American Foundation for Suicide Prevention, the ESRC, and the UCL Institute of Mental Health. She is a patron of the Support After Suicide Partnership.

S.R. is employed by UCL and has no conflicts of interest to declare

Primary paper

Arshad U. et al. (2020) A systematic review of the evidence supporting mobile- and internet-based psychological interventions for self-harm. Suicide and Life-Threatening Behavior. 50(1)151-179

Reference List

(1)    Hawton K, Bergen H, Casey D, Simkin S, Palmer B, Cooper J, et al. Self-harm in England: a tale of three cities. Soc Psychiatry Psychiatr Epidemiol 2007;42(7):513-21.

(2)    Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLOS One 2014 Feb 28;9(2):e89944.

(3)    Geulayov G, Casey D, Bale L, Brand F, Clements C, Farooq B, et al. Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study. The Lancet Psychiatry 2019 Dec 1;6(12):1021-30.

(4)    Geulayov G, Casey D, McDonald KC, Foster P, Pritchard K, Wells C, et al. Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study. The Lancet Psychiatry 2018 Feb 1;5(2):167-74.

(5)    Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, et al. Interventions for self-harm in children and adolescents. Cochrane Database of Systematic Reviews 2015;CD012013(12).

(6)    Perry Y, Werner-Seidler A, Calear AL, Christensen H. Web-Based and Mobile Suicide Prevention Interventions for Young People: A Systematic Review. J Can Acad Child Adolesc Psychiatry 2016;2016/05/01(2):73-9.

(7)    Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, et al. Psychosocial interventions for self-harm in adults. Cochrane Database of Systematic Reviews 2016;(5).

(8)    Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, et al. Suicide risk and prevention during the COVID-19 pandemic. The Lancet Psychiatry 2020.

(9)    Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. The Lancet Psychiatry 2020.

(10)    Witt K, Spittal MJ, Carter G, Pirkis J, Hetrick S, Currier D, et al. Effectiveness of online and mobile telephone applications (‘apps’) for the self-management of suicidal ideation and self-harm: a systematic review and meta-analysis. BMC Psychiatry 2017;17(1):297.

(11)    Torok M, Han J, Baker S, Werner-Seidler A, Wong I, Larsen ME, et al. Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials. The Lancet Digital Health 2020 Jan 1;2(1):e25-e36.

Discussion

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I want reference for selfharm support document.

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