2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.

2.1 Effectiveness of training

For healthcare professionals who work with people who self-harm, does the provision of training in assessment and management improve outcomes compared with no additional specialist training?

A well-powered randomised controlled trial should examine the effectiveness of training. Researchers should consider the format and length of training. The outcomes chosen should include both healthcare professionals' and service users' evaluation of the training, and the effect on subsequent knowledge, attitude and behavioural changes. It should include longer-term follow-up of 12 months or more.

Why this is important

Current studies of training have been limited in their assessment of changes in healthcare professionals' knowledge, attitudes and behaviour. Crucially no studies have examined whether training has any impact on service users' experience and outcomes. Healthcare professionals frequently report that treating service users who self-harm is challenging and they are likely to find training helpful as it provides an opportunity to think about and understand this aspect of their work. Studies to date, however, have not looked beyond these initial outcomes of training, which are more indicative of satisfaction with training rather than addressing whether training has had an impact on practice, service user experience and outcomes. Future research should consider a wider range of outcomes – for example, attitudes, changes in assessment practice, changes in interventions and improvement in service user experience and outcomes. The longer-term impact of training should also be assessed.

2.2 Clinical and cost effectiveness of psychological therapy with problem-solving elements for people who self-harm

For people who have self-harmed, does the provision of a psychological therapy with problem-solving elements, compared with treatment as usual, improve outcomes? What is the differential effect for people with a past history of self-harm, compared with people who self-harm for the first time?

This question should be answered using a well-conducted randomised controlled trial. Consider six sessions of psychological therapy with problem-solving elements, delivered immediately after discharge for the index episode of self-harm. The therapist should be trained and experienced in working with people who self-harm. Participants' history of previous self-harm, methods used and psychiatric history should be noted. Primary outcomes should include both hospital-reported and self-reported repetitions of self-harm. Other important outcomes, such as quality of life, depressive symptoms, service users' experience and adverse events (for example, distress or exacerbation of symptoms associated with therapy) should be included. The study design should take into account the complex motives that underpin self-harm. Studies need to be large enough to determine the intervention's costs and cost effectiveness.

Why this is important

Although review of the research evidence suggests that psychological therapy with problem-solving elements offers promise, it is not clear which components are the active ingredients of any such intervention, or whether such an intervention is effective for people with a past history of self-harm compared with those who have self-harmed for the first time. Further, only a few studies have looked at a broad range of outcomes for different populations who self-harm.

2.3 Clinical effectiveness of low-intensity/brief psychosocial interventions for people who self-harm

For people who self-harm, does the provision of potentially cheap low-intensity/brief psychosocial interventions, compared with treatment as usual, improve outcomes?

This question should be answered using a well-conducted randomised controlled trial. Consider using a variety of approaches, including postcards, emergency cards, phone calls, or the use of electronic media in community mental health settings. The outcomes should include service users' engagement and experience, and hospital-reported and self-reported repetitions of self-harm. Other important outcomes, such as quality of life, depressive symptoms and adverse events (for example, distress or exacerbation of symptoms associated with contact with services) should be included.

Why this is important

Many people do not engage with available treatments following self-harm. If acceptable, alternative approaches, such as the low-intensity contact interventions indicated above, can be relatively easily and widely implemented, with the potential to improve outcomes, at relatively low cost, in individuals who may be otherwise difficult to engage.

2.4 Observational study exploring different harm-reduction approaches

What are the different approaches to harm reduction following self-harm in NHS settings?

A study should be carried out to investigate the different approaches to harm reduction following self-harm currently in use in NHS settings. This could use survey methodology with all, or a selected sample of, mental health service providers. Audit data should be used to provide a preliminary evaluation of potential utility. Promising interventions might be tested in small-scale pilot randomised controlled trials, which use frequency and severity of self-harm, and standard measures of distress and psychological symptoms, as outcome measures. Other outcomes such as quality of life, service users' experience and adverse events should be included.

Why this is important

Although cessation of the behaviour remains the treatment goal for many professionals providing care to people who self-harm, this may not be realistic or possible in the short term for some individuals. An alternative strategy for services is to reduce the severity and frequency of self-harm. Anecdotally, a variety of approaches to harm reduction are used in health service settings – for example, minimising the physical harm associated with episodes or suggesting alternatives to self-harming behaviours. However, the extent to which such management strategies are used across services is uncertain, as is their effectiveness.

  • clinical guideline 16 (2004).

More information

You can also see this guideline in the NICE pathway on self-harm.

To find out what NICE has said on topics related to this guideline, see our web page on mental health and behavioural conditions.

See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.

  • National Institute for Health and Care Excellence (NICE)