The Efficacy of a Cognitive-Behavioural Intervention in Deliberate Self-Harm Patients: A Randomized Controlled Trial Among Adolescents and Young Adults

1. The development of treatment interventions for non-fatal deliberate self-harm (DSH) among young people has received little attention in scientific literature and in mental health care. This is surprising, considering the relatively high rates of hospital-referred DSH among adolescents reported in epidemiological studies (Arensman et al., 1995; Hawton et al., 1997; Hawton et al., 1998; Schmidtke et al., 1996). On the basis of a four-year monitoring study (1989-1992) in the area of Leiden, the average rate of DSH among females aged 15-24 was 179 per 100,000 and for males in this age group the average rate was 91 per 100,000 (Arensman et al., 1995). General population surveys among adolescents show a self-reported life-time prevalence of 2 to 5 percent (Kienhorst et al., 1990; De Wilde et al., 2000). Reports from other European countries indicate an increase of DSH in adolescents and young adults (15-30 years), in particular in young males (Hawton et al., 1997; Schmidtke et al., 1996).

DSH is operationalized as dysfunctional behaviour associated with a heterogeneity of psychological or psychiatric disorders e.g., affective disorders, anxiety disorders, substance abuse, and eating disorders (Arensman & Kerkhof, 1996; Arensman, 1997; Ellis et al., 1996; Engstroem et al., 1996; Kienhorst et al., 1993). However, a common finding is that depressive symptoms (observer- or self-rated) and major depression appear to be highly prevalent among young DSH patients (Burgess et al., 1998; Goldston et al., 1998; Harrington et al., 1994). In these studies, co-morbidity with other types of psychopathology also appeared to be relatively high.

The risk of repeated DSH is highest in the first year following an episode of DSH. The repetition rates among young DSH patients vary from 10% (Goldacre & Hawton, 1985) to 27% (Arensman, 1997) in hospital referred DSH patients. Among DSH patients, prevention of the first subsequent repeated episode of DSH is important in order to prevent a pattern of chronic repetition.

Research findings with regard to risk factors associated with repeated DSH are fairly consistent. Among young DSH patients, those with an increased risk for repeated DSH are characterised by suicidal ideation, depression (Harrington et al., 2000; Hawton et al., 1999), hopelessness (Brent, 1987; Hawton et al., 1999), impulsivity (Kashden et al., 1993), disturbance of autobiographical memory (Evans et al., 1992), problems with peers or other relationships, frequent or chronic stress and problem-solving deficits (De Wilde et al., 2000; Hawton et al., in press; Rudd et al., 1998).

Despite the fact that many studies report these correlates, the available treatment studies, which merely comprise evaluations of general treatment interventions, often without a randomised controlled design, have not incorporated knowledge about risk factors (Hawton et al., 1998). In addition, existing explanatory and treatment models do not address the heterogeneity of the group of DSH patients. This is surprising, considering the variety of characteristics and problems of DSH patients. So far, most models focus on single psychiatric problems, such as depression or anxiety disorders.