Self-Injurious Behavior Clinical Trial
Official title:
Text Message Intervention to Reduce Repeat Self-harm in Patients Presenting to the Emergency Department
Between 6% and 30% of people who harm themselves repeat this self-harm within the following
12 months. The investigators know that people who harm themselves are much more likely to
commit suicide, but the investigators have no clear evidence about the best way to reduce
the likelihood of someone harming themselves again.
Text messaging is now a common form of communication. Previous research has shown us that
the investigators can use text messages for different types of health care interventions.
Examples of this include reminding patients of medical appointments, delivering test
results, to check patient side effects following treatment and to reduce depressive symptoms
in patients with depression and alcohol problems. The Samaritans have introduced interactive
text messages (where you can have a conversation by text with their service) and have noted
an increasing use of this contact with their service.
This research study is taking place to find out if using supportive and interactive text
messages can reduce further episodes of self-harm in patients who present to the Emergency
Department (ED) with self-harm.
The investigators hypothesize that supportive, informative and interactive text messages
delivered to patients discharged from an ED after an episode of self-harm will significantly
reduce the frequency and intensity of thoughts of self-harm and self-harming behaviour in
patients compared with those receiving only follow-up treatment as usual. A secondary
hypothesis is that patients receiving the text messages will report a favourable experience
and an overall satisfaction with the system.
Repetition of self-harm is common, ranging from 6% to 30% in 12 months. Repetition is
strongly associated with subsequent suicide and has important implications for healthcare
resources. In every country including Ireland, fatal suicide attempts rank among the top ten
causes of death for individual of all ages and one of the three leading causes of death in
the 15 -35 years age group.
Previous studies of interventions to reduce the repetition of self-harm in unselected
patient groups have been unsuccessful in reducing the proportion of repeaters. These
interventions have included the use of antidepressants, problem solving, intensive care with
outreach, an emergency card, psychosocial crisis intervention, and guaranteed inpatient
shelter in cases of emergency. In a study involving the use of low cost postcards after an
episode of self-poisoning, although no significant difference in the proportion of
individual patients who repeated self-harm were detected, there was a clinically and
statistically significant reduction in the number of events per individual by about 50%.
Only a few non-pharmacological interventions have been reported to be effective in reducing
repetition in selected subsets of populations with self-harm including; partial
hospitalization, dialectical behaviour therapy and psychodynamic interpersonal therapy.
These interventions are all resource intensive and therefore may only be applicable to
carefully selected patients.
Given the recent global financial crisis with consequent diminution of health care
resources, interventions are needed that could be delivered economically to entire
populations of patients who self-harm. In light of the growing interest in using text
messages as an intervention in healthcare, the investigators will focus in this study on
exploring the potential for using text messages to reduce repeat self-harm in patients
presenting to the Emergency Department (ED).
There is established research evidence for using text messages to remind patients of
scheduled medical appointments, to coordinate medical staff,to deliver medical test results
and to monitor patient side effects following treatment.
In a review of the literature on the use of text messaging for clinical and healthy
behaviour interventions, Wei et al. (2011) found that among 16 randomized controlled trials,
10 reported significant improvement with interventions and six reported differences
suggesting positive trends. In one meta-analysis of four randomised trials of mobile
phone-based interventions for smoking cessation, it was reported that text message
interventions resulted in a significant increase in short-term self-reported quitting (RR of
2.18, 95% CI 1.80 to 2.65). In the same review, when data from an internet and a mobile
phone programme were pooled and meta-analysed, they found significant increases in both
short-, and long-term, self-reported quitting (RR of 2.03, 95% Conficence Intervals (CI)=
1.40 to 2.94).
In a study of text message services based on qualitative interviews with 12 young people,
the aim of which was to provide young people with information on cannabis and help them to
reduce their consumption of the drug, participants reported that they saw the messages as
flexible and discrete, and as being personally meant for them. They paid more attention to
the messages than they did to mass approaches such as public information broadcasts on TV.
Along with other factors, the participants reported feeling motivated to decrease their
level of cannabis abuse and to maintain a reduced level. .
In another study, young adults in 3 urban EDs (n= 45; aged 18 to 24 years, 54% women) who
were identified as hazardous drinkers by the Alcohol Use Disorders Identification
Test-Consumption Score were randomly assigned by the researchers to weekly text
message-based feedback with goal setting (Intervention), weekly text message-based drinking
assessments without feedback (Assessment), or to a control who received no text messages. At
3 months, they found that participants who were exposed to the text message-based
intervention had 3.4 (Standard Deviation (SD)= 5.4) fewer heavy drinking days in the last
month and 2.1 (SD 1.5) fewer drinks per drinking day when compared to baseline.
In a recent randomised trial in Ireland of supportive text messages for patients with
depression and comorbid alcohol use disorder, there was a trend towards finding a greater
cumulative abstinence duration in the group that received twice daily supportive text
messages compared to the control group who only received fortnightly tank you text messages:
88.3 (SD=6.2) vs. 79.3 (SD=24.1), t=1.78, df=48, p=0.08. In this trial, after adjusting for
baseline scores, patients in the supportive text message group also had significantly lower
Beck's Depression Inventory Scores compared to the control groups; 8.5 (SD=8.0) vs. 16.7
(SD=10.3) respectively, F (1, 49) = 9.54, p=0.003, ƞp2=0.17.
In a study by Owens et al. (2010) to engage a group of self-harmers in the development of a
text-messaging intervention to reduce repetition of self-harm, three broad categories of
message emerged, namely, those that affirmed or validated emotions (e.g. "it's ok to feel
angry"), those that prescribed actions, distractions or cognitive strategies (e.g. "call
Samaritans," "have a warm bath"," take it a minute at a time") and those that were
interrogative or designed to initiate dialogue (e.g. "do you want to talk?"). They also
found that the group were unable to reach an agreement on a set of messages that might work
in all circumstances to reduce the urge to self-harm or to enable people to feel cared for,
concluding instead that text messages may need to be individualised. A major limitation of
this study was its small sample size of only 8 people. Furthermore, participants in this
study only reported how they envisaged they would respond to text messages rather than how
they actually responded to text messages which could vary significantly from what is
reported. In the recent randomised trial in Ireland of generic supportive text messages for
patients with depression and comorbid alcohol use disorder, 20 of the 24 patients (83%)
reported that the intervention had played a useful role in helping to improve their mental
health.
Recently, the Samaritans in Ireland introduce a limited interactive text message programme
for patients who experience suicidal ideation. This service allows clients to receive
support when in crisis via an interactive text messaging programme from a trained volunteer.
After an extensive review of the literature using Google Scholar, MEDLINE, Pub Med, ERIC,
Web of Science, Science Direct and PsychINFO, no published randomised trial was found on the
use of text messages delivered via mobile phone as an intervention to address suicidal
ideation and repeat self-harm in patients presenting with self-harm to the ED. Thus, the
investigators seek to determine if text messaging is a useful and effective strategy to help
reduce the frequency and intensity of thoughts of self-harm and depressive symptoms after
patients are discharged from an ED following a presentation with self-harm.
The investigators hypothesize that supportive, informative and interactive text messages
delivered to patients discharged from an ED after an episode of self-harm will significantly
reduce the frequency and intensity of thoughts of self-harm and self-harming behaviour in
patients compared with those receiving only follow-up treatment as usual. A secondary
hypothesis is that patients receiving the text messages will report a favourable experience
and an overall satisfaction with the system.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Outcomes Assessor), Primary Purpose: Prevention
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