Can brief text messaging reduce repeat hospital-treated self-harm?

Self-harm is defined as “intentional self-poisoning or injury, irrespective of the apparent purpose” (National Institute for Health and Care Excellence, 2022, p. 81). Rates of self-harm have turn into extra prevalent, with 25.7% of girls, and 9.7% of guys, reporting self-harm across their life (McManus et al., 2016). Differential prices of self-harm have been reported for these who determine as LGBTQ+ (Liu et al., 2019), these from non-white ethnic backgrounds (Bhui et al., 2007) and these from deprived socio-financial backgrounds (Geulayov et al., 2022). Self-harm is also linked with suicidality (Geulayov et al., 2019). Overall, self-harm is a complicated and life-threatening phenomenon one particular that warrants considerable focus.

The present study, by Stevens and colleagues (2024), seeks to determine whether or not a brief text message intervention could help in minimizing the quantity of instances that people today need to have to return to hospital for self-harm remedy. The randomised controlled trial (RCT), by Steven and colleagues (2024), is the initial to discover this kind of intervention on a broader population in Australia. Previous analysis has been focused on certain populations, like military personnel, thus, this study has the possible to contribute to the interventions’ generalisability to a wider group of people today.

Methods

Stevens et al., (2024) performed a parallel RCT which compared participants who received remedy as usual (TAU), with participants who received TAU, plus nine brief quick message service (SMS) messages more than 12 months, immediately after their discharge from 3 hospitals in New South Wales, Australia.

The SMS intervention integrated 3 unique messages sent to participants on a rotating schedule. All SMS messages had been personalised with the participants name, integrated an expression of concern for participant wellbeing, and integrated specifics of accessible regional mental overall health solutions and crisis lines. The messages had been created by consultants with lived knowledge.

Once enrolled, participants had been stratified by initial and subsequent self-harm presentation as there was considerable variability amongst participants. After stratification, participants had been then randomly assigned and enrolled by clinicians into either the TAU or TAU plus SMS situation. The allocation sequence was concealed.

The study also interestingly applied a single-consent Zelen design and style (Zelen, 1979) which has been discussed in preceding a preceding weblog by Lucy Maconick (2022). The Zelen design and style is a modification to a usual RCT, whereby participants in the intervention group only are asked to supply consent immediately after randomisation. As the study applied a Zelen design and style, this meant that the participants had been not blinded to becoming in the SMS situation.

Results

The study enrolled 431 participants into the TAU group and 373 participants into the TAU plus SMS group. There was a bigger proportion of females (n=520) to males (n=284). The study had key 3 main outcomes, and two secondary outcomes.

Primary outcomes

• The quantity of instances that people today repeated self-harm, and necessary hospital remedy for this, lowered drastically at 12 and 24 months, immediately after getting TAU plus the SMS intervention, with a relative threat reduction (RRR) of 22%. The authors state that at the 24-month comply with-up, this 22% equates to 123 much less people today re-presenting for self-harm remedy in the SMS group.
• Females had larger prices of re-presentation for self-harm, but the impact of the brief text message was considerable and bigger for females compared to males, exactly where there was no distinction among TAU and TAU plus intervention concerning the frequency of repeat, hospital treated, self-harm.
• There was no distinction, among TAU and TAU plus intervention, in the time among when participants initial presented to hospital with self-harm, to when they presented to hospital once more for self-harm, more than the 24-month comply with-up period.

Secondary outcomes

• There was no distinction among TAU and TAU plus intervention concerning the proportion of participants who repeated self-harm or not, more than the 24-month comply with-up period of the study, which means the intervention did not reduce the quantity of instances people today repeated self-harm.
• Throughout the study, more than the 24-month period, there had been a total of 16 deaths.
• The study also analysed suicide prices amongst the 16 deaths and sadly discovered that there had been 4 suicides across the 24-month period. The authors stated that the suicides occurred in the TAU group only.

Conclusions

Overall, this study shows that a brief text message intervention could reduce the quantity of instances that people today return to hospital for remedy of repeat self-harm. The authors also state that “the 22% reduction in repetition of hospital-treated self-harm was clinically meaningful” (Stevens et al., 2024, p. 106). This is an crucial discovering, offered how simply implementable such an intervention could be, as it is brief and automated. However, the authors argue that it is probably that extra research are necessary to establish additional efficacy and financial feasibility of the SMS intervention.

Strengths and limitations

The RCT, by Stevens et al., (2024), was the initial to discover a brief SMS intervention in a population beyond a narrow demographic. By exploring a wider population, this study supplied proof that the intervention could have efficacy in hospital settings, exactly where a massive proportion of the population seek self-harm remedy. As this was an RCT, the study was randomised, which is a further strength, as this aids to enhance internal validity. It was also fantastic to see that messages integrated in the intervention had been designed by people today with lived mental overall health knowledge, probably enhancing their appropriateness.

However, the study applied non-standardised TAU situation. Although this could be argued as extra correct, as there is variability in clinical settings, it could confound final results. Witt et al. (2018) state that non-regular TAU is a considerable supply of heterogeneity in research that investigate self-harm interventions, and it is crucial to have clarity concerning what constitutes TAU. Although the authors did detail what TAU was probably to consist of, they stated that it varied, which could have influenced outcomes. For instance, if one particular participant received a care program that did not contain psychological therapies, compared to a further participant that did obtain psychological therapies, this could have brought on confounding variables.

Another key limitation was the single-consent Zelen design and style. Although the Zelen design and style can enhance drop-out prices, as participants may perhaps be happier to be allocated to the remedy situation (Homer, 2002), the single-consent Zelen design and style asked for consent in the remedy group only, which the authors state led to improved attrition prices, which could have led to attrition bias. Participants in the remedy situation had been also conscious of their allocation, which could have altered participant behaviour, eventually impacting the validity of the study. Additionally, the study did not make clear whether or not the researchers had been blinded, so this may perhaps have additional impacted the findings.

Implications for practice

Self-harm is a considerable burden on the wellbeing of the Australian population (Australian Institute of Health and Welfare, 2019), thus the implications of the reduction in repeat self-harm occasion prices are considerable for individuals, solutions and practitioners.

Qualitative analysis has demonstrated that brief SMS interventions may perhaps be beneficial to people today who are self-harming by fostering a sense of feeling supported by means of caring messages, and information and facts about solutions, if urgent mental overall health help is necessary (Duan et al., 2020). This method to patient aftercare thus may perhaps reduce demand on stretched Australian emergency departments (Australian Institute of Health and Welfare, 2023), as messages encourage individuals to use help helplines for preventative self-harm care. However, prior to implementation, additional analysis should discover why individuals are re-presenting much less, and whether or not crisis lines, or supportive messages, are a casual mechanism by which re-presentation prices are lowered. Knowing the precise casual mechanisms will make certain interventions are efficacious, ease demand, and attain the ideal outcomes in terms of self-harm reduction.

As the UK experiences the identical issues as Australia, like higher demand for urgent solutions (Pines et al., 2011), and increases in self-harm (McManus et al., 2016), the identical implications apply. As the NHS moves towards supplying Enhanced Primary Care Services, which contain mental overall health solutions for people today with extra complicated presentations, such an intervention may perhaps provide practitioners an simply implementable tool which could assistance reduce escalation to secondary care and enhance mental overall health literacy each outcomes have the possible to improve patient security and knowledge in main care, specially for extra at-threat individuals. Further analysis is necessary to discover an SMS intervention in main care settings to establish the efficacy of the intervention.

Finally, the expense-effectiveness of the intervention should be examined. There is proof to recommend that digital overall health interventions can be expense-efficient (Gentili et al., 2022), which could make an SMS intervention feasible in the NHS, without the need of adding considerable monetary burden. In the Talking Therapies service that I operate inside, the service has an established automated SMS service, which may perhaps be the case across other solutions, so it could be simply implementable with small further sources.

Overall, a brief SMS intervention could be implemented inside mental overall health solutions to reduce burden on urgent solutions and enhance the wellbeing of the recipients, having said that, extra analysis is necessary concerning mechanisms of transform, generalisability and financial viability ahead of adoption.

Statement of interests

No conflicts of interest to declare.

Links

Primary paper

Stevens, G. J., Sperandei, S., Carter, G. L., Munasinghe, S., Hammond, T. E., Gunja, N., de la Riva, A., Brakoulias, V., &amp Page, A. (2024). Efficacy of a quick message service brief make contact with intervention (SMS-SOS) in minimizing repetition of hospital-treated self-harm: randomised controlled trial. The British Journal of Psychiatry, 224(3), 106–113. https://doi.org/10.1192/bjp.2023.152

Other references

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Australian Institute of Health and Welfare. (2023). Emergency division care. https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care

Bhui, K., McKenzie, K., &amp Rasul, F. (2007). Rates, threat aspects &ampamp strategies of self harm amongst minority ethnic groups in the UK: a systematic assessment. BMC Public Health, 7(1), 336. https://doi.org/10.1186/1471-2458-7-336

Duan, S., Wang, H., Wilson, A., Qiu, J., Chen, G., He, Y., Wang, Y., Ou, J., &amp Chen, R. (2020). Developing a Text Messaging Intervention to Reduce Deliberate Self-Harm in Chinese Adolescents: Qualitative Study. JMIR MHealth and UHealth, 8(6), e16963. https://doi.org/10.2196/16963

Gentili, A., Failla, G., Melnyk, A., Puleo, V., Tanna, G. L. Di, Ricciardi, W., &amp Cascini, F. (2022). The expense-effectiveness of digital overall health interventions: A systematic assessment of the literature. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.787135

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Geulayov, G., Casey, D., Bale, L., Brand, F., Clements, C., Farooq, B., Kapur, N., Ness, J., Waters, K., Tsiachristas, A., &amp Hawton, K. (2019). Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a lengthy-term comply with-up study. The Lancet Psychiatry, 6(12), 1021–1030. https://doi.org/10.1016/S2215-0366(19)30402-X

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