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Question In children and adolescents who have deliberately poisoned themselves, can a home based family intervention by child psychiatric social workers reduce suicidal feelings and improve family functioning?
Randomised controlled trial with 6 months follow up.
4 hospitals in Manchester, UK.
162 patients, ≤16 years of age (mean age 15 y, 90% girls), who had deliberately poisoned themselves. Exclusion criteria were self harm such as cutting or attempted hanging; family situation precluding a family intervention; or clinical or psychiatric contraindication. 149 patients (92%) were assessed at 6 months.
85 patients were allocated to routine care plus a home based family problem solving intervention, and 77 were allocated to routine care only. The home based intervention consisted of an assessment session and 4 home visits by psychiatric social workers. The routine care group received no home visits.
Main outcome measures
The primary outcome measures were changes on the Suicidal Ideation Questionnaire, the Hopelessness Scale, and the Family Assessment Device. The secondary outcome measures were changes on a subscale of the Social Problem Solving Inventory, the General Health Questionnaire, and a scale of satisfaction with treatment.
Analysis was by intention to treat. No treatment effects existed between the groups for the primary outcome measures (table). The only difference between the groups for secondary outcome measures was that parents in the intervention group were more satisfied with treatment at 2 months follow up (table). The study had slightly <80% power to detect a mean Suicidal Ideation Questionnaire score of 24 after active treatment (an effect size of 0.46). In a subgroup analysis, non-depressed patients in the intervention group had less suicidal ideation than non-depressed patients in the control group at 2 and 6 months follow up (p<0.01).
A home based family intervention for children who had deliberately poisoned themselves did not reduce suicidal ideation or improve family functioning.
This study by Harrington et al is among the few to systematically evaluate the efficacy of an intervention designed to reduce suicidal tendencies in adolescents—a much needed endeavour to augment clinical practice strategies. Despite the prevalence of family discord as an important risk factor for youth suicidal behaviour, other controlled family intervention studies have failed to show efficacy to reduce suicidal tendencies.1–3 Several issues require consideration and suggest reasons for such apparent failures. Firstly, suicidal ideation was the main outcome but this is related to multiple factors, such as the presence of major depression. The intervention was not aimed to address this issue as well as the specified family discord. Research designed to address the adolescents' psychopathology coupled with treatment of family conflicts may be a promising area for intervention. Secondly, this study did not try to evaluate whether family intervention could decrease suicidal attempts. It cannot be concluded that a family oriented approach is ineffective for this outcome. Thirdly, this study shows that there are other factors deserving of attention in understanding treatment efficacy. These involve the characteristics of the targeted population (in this case, predominantly depressed girls), and characteristics of specific interventions which are given over specified time periods.
This is an important endeavour but highlights the need for future research. Other treatment studies are needed that include modifications in design, that target different samples, and that focus on multiple risk factors.
Source of funding: Department of Health, UK.
For correspondence: Professor R Harrington, Department of Child and Adolescent Psychiatry, Royal Manchester Children's Hospital, Manchester M27 1HA, UK. Fax +44 (0)161 728 2294.
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